ࡱ> q` `bjbjqPqP *::S^^^DN3N3N3N324T*b4 ????A N T6b8b8b8b8b8b8b$mche\b^ZoA|AZZ\b??Yqb```Z?^?6b`Z6b``Va@(6^a?4 vN3[a "bb0ba Wff^ WfaWf^a$WX|`YdsYWWW\b\b`WWWbZZZZ***$N3***N3rD, DUI AFFIDAVIT-INFRARED CASE#___________________ Page 1 of 4 Revised 8/06 NOW COMES__________________________, affiant, being duly sworn and on oath, deposes and states that I have probable cause to believe that ____________________________________, hereinafter referred to as operator and defendant, committed the offense of Driving Under the Influence in violation of 23 V.S.A. 1201. In support of this charge the affiant states: I am a law enforcement officer certified by the Vermont Criminal Justice Training Council. I am trained and certified by the Vermont Criminal Justice Training Council to operate the DataMaster infrared breath-testing instrument. On__________________ at _____________hours, the defendant was operating/attempting to operate/in actual physical control, of a (year/make/model)_________________________________, registration ____________________ on a public highway known as _______________________ in the town/city of __________________ in the county of in the State of Vermont. A.  FORMCHECKBOX  I made the following observations of defendants operation that resulted in my making this stop: (IF ADDITIONAL SPACE IS NEEDED, ATTACH A DESCRIPTION OF THE FACTS AS PAGE 1-A) OR B.  FORMCHECKBOX  Although I did not observe operation in this case, I was able to determine that the defendant operated said vehicle at __________hours based upon the evidence described on page 1-A of this affidavit. (If officer did NOT observe the driving, submit with case statements from witnesses establishing that this accused drove the vehicle, the approximate TIME, and the public highway.) 4. OBSERVATION OF OPERATOR Odor of intoxicants  FORMCHECKBOX Strong  FORMCHECKBOX Moderate  FORMCHECKBOX Faint  FORMCHECKBOX None Eyes  FORMCHECKBOX Watery  FORMCHECKBOX Bloodshot  FORMCHECKBOX Normal Speech  FORMCHECKBOX Unintelligible  FORMCHECKBOX Mumbled  FORMCHECKBOX Slurred  FORMCHECKBOX Confused  FORMCHECKBOX Normal 1. Have you consumed any alcoholic beverages?   FORMCHECKBOX No  FORMCHECKBOX Yes: How many? _______________ 2. How long ago was your first drink? ____________ 3. How long ago was your last drink? ____________ 4 How much, if anything, have you had to drink in the last 30 minutes?___________________________ 5. Have you consumed any drugs or medications?  FORMCHECKBOX No  FORMCHECKBOX Yes: What?__________________________ 6. Other observations (e.g. alphabet, counting, etc.):_______________________________________________ 7. Difficulty getting out of vehicle?  FORMCHECKBOX No  FORMCHECKBOX Yes: Describe: ____________________________________ Standing  FORMCHECKBOX Falling  FORMCHECKBOX Extreme Sway  FORMCHECKBOX Slight Sway  FORMCHECKBOX Unsteady  FORMCHECKBOX Steady Walking  FORMCHECKBOX Falling  FORMCHECKBOX Stumbling  FORMCHECKBOX Unsteady  FORMCHECKBOX Steady Alcoholic containers in vehicle?  FORMCHECKBOX No  FORMCHECKBOX Yes #_________Types:_________________________  FORMCHECKBOX Full  FORMCHECKBOX Empty  FORMCHECKBOX None 5. SOBRIETY EXERCISES Is there any reason that the operator cannot perform these exercises?  FORMCHECKBOX No  FORMCHECKBOX Yes: Explanation (e.g. roadway, health, etc.): _____________________________________________________________________________________________________ L. EYE R. EYE  FORMCHECKBOX Lack of smooth pursuit  FORMCHECKBOX   FORMCHECKBOX  HGN  FORMCHECKBOX Distinct jerkiness at maximum deviation  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX Onset of distinct jerkiness prior to 45(  FORMCHECKBOX   FORMCHECKBOX  _______ Total Clues(decision point-4 clues)  FORMCHECKBOX Cant balance during instructions  FORMCHECKBOX Starts before instructed  FORMCHECKBOX Incorrect number of steps Walk  FORMCHECKBOX Stops walking to steady self  FORMCHECKBOX Does not touch heel to toe  FORMCHECKBOX Cannot do exercise & Turn  FORMCHECKBOX Loses balance/steps off line  FORMCHECKBOX Uses arms for balance (steps off line 3 times)  FORMCHECKBOX Loses balance while turning/turns incorrectly ________Total Clues (decision point-2 clues) One  FORMCHECKBOX Sways while balancing  FORMCHECKBOX Hopping Leg  FORMCHECKBOX Cannot do exercise (puts foot down 3 times)  FORMCHECKBOX Puts foot down Stand  FORMCHECKBOX Uses arms to balance (raises arms more than 6 inches) ________Total Clues(decision point-2 clues) Comments (e.g. shoes, etc.): Officers opinion of Impairment  FORMCHECKBOX None  FORMCHECKBOX Slight  FORMCHECKBOX Moderate  FORMCHECKBOX Substantial  FORMCHECKBOX Extreme PBT Result _________% BAC at _________Hrs. Model:___________ Serial #____________ DUI AFFIDAVIT INFRARED Page 2 of 4 Revised 8/06 TIME OBSERVATION OF OPERATOR STARTED:__________Hrs. Timepiece used:______________________ 6. BEFORE WE GO ANY FURTHER I WANT TO EXPLAIN THESE RIGHTS TO YOU: (Check as read.)  FORMCHECKBOX You have the right to remain silent.  FORMCHECKBOX Anything you say can and will be used against you in a court of law.  FORMCHECKBOX You have the right to talk to a lawyer before questioning and to have a lawyer present with you during questioning.  FORMCHECKBOX If you cannot afford to hire a lawyer, one will be appointed to represent you at public expense, before any questioning , if you wish. In Vermont, that is called a public defender.  FORMCHECKBOX If you decide to answer questions, you may stop the questioning at any time.  FORMCHECKBOX Do you understand each of these rights I have explained to you? Reply:  FORMCHECKBOX Yes  FORMCHECKBOX No________________________  FORMCHECKBOX Do you want to talk to me now? Reply:  FORMCHECKBOX Yes  FORMCHECKBOX No _________________________________________________ If answer is NO, OFFICER SHOULD STOP, and say the following:  FORMCHECKBOX  There will be no questions. I will now go to the subject of evidentiary testing. (OFFICER SHOULD GO IMMEDIATELY TO No. 8 IMPLIED CONSENT on page 3). If answer is YES, OFFICER SHOULD READ THE WAIVER to defendant and ask if she/he wishes to sign, as follows: WAIVER  FORMCHECKBOX  I have been advised that I have the right to remain silent, to be represented by a lawyer, to talk with one prior to questioning and to have one present during questioning. Knowing my rights, I agree to waive them and talk to you now. No threats or promises have been made to me. __________________________________ _______________________________________ Date/Time (Specify timepiece used) Operators Signature (or time of taping) Comments: If defendant declines the waiver or requests a lawyer, OFFICER SHOULD STOP, and say the following:  FORMCHECKBOX  In that event, you are hereby notified that I will not ask you any questions. We will now go to the subject of evidentiary testing. After that, you will have an opportunity to talk with a lawyer before making your decision whether to take or refuse the test. (OFFICER SHOULD GO IMMEDIATELY TO No. 8. IMPLIED CONSENT on page 3). 7. INTERVIEW Where were you driving to? ____________________________________________________________________ Where were you driving from (this time)? _________________________________________________________ How long ago did you drive from that location? ____________________________________________________ What food have you eaten in the last six hours? _____________ How long ago did you eat that?______________ What have you been drinking?  FORMCHECKBOX Beer  FORMCHECKBOX Liquor  FORMCHECKBOX Wine Specific type (brand/name of drink)________________________________ How many drinks of each kind did you have? ______________________________________________________ How long ago did you start drinking? __________ How long ago did you stop drinking? ____________________ How much if anything did you drink in the 30 minutes before you were stopped driving? ____________________ Who were you drinking with? (obtain names)______________________________________________________ Where (specific location) were you drinking? ______________________________________________________ How much do you weigh? ___________ Are your tired?  FORMCHECKBOX No  FORMCHECKBOX Yes Are you ill?  FORMCHECKBOX No  FORMCHECKBOX Yes, if so describe: _________________________________ Do you have any physical handicaps?  FORMCHECKBOX No  FORMCHECKBOX Yes, if so describe: ______________________________________ Do you limp?  FORMCHECKBOX No  FORMCHECKBOX Yes Do you have diabetes?  FORMCHECKBOX No  FORMCHECKBOX Yes Taking insulin?  FORMCHECKBOX No  FORMCHECKBOX Yes Do you have epilepsy?  FORMCHECKBOX No  FORMCHECKBOX Yes Have you been injured lately?  FORMCHECKBOX No  FORMCHECKBOX Yes, if so describe:____________________________________________ Do you wear glasses?  FORMCHECKBOX No  FORMCHECKBOX Yes Do you wear contact lenses?  FORMCHECKBOX No  FORMCHECKBOX Yes In the last 24 hours have you taken any medications or drugs?  FORMCHECKBOX No  FORMCHECKBOX Yes Were the drugs/medications affecting your driving?  FORMCHECKBOX No  FORMCHECKBOX Slightly  FORMCHECKBOX Moderately  FORMCHECKBOX Substantially Please describe what drug/medication and the dosage/amount consumed? ________________________________ Are you under the influence of drugs right now?  FORMCHECKBOX No  FORMCHECKBOX Slightly  FORMCHECKBOX Moderately  FORMCHECKBOX Substantially Are you under the influence of alcohol now?  FORMCHECKBOX No  FORMCHECKBOX Slightly  FORMCHECKBOX Moderately  FORMCHECKBOX Substantially Were you under the influence of drugs while driving the vehicle?  FORMCHECKBOX No  FORMCHECKBOX Slightly  FORMCHECKBOX Moderately  FORMCHECKBOX Substantially Were you under the influence of alcohol while driving the vehicle?  FORMCHECKBOX No  FORMCHECKBOX Slightly  FORMCHECKBOX Moderately  FORMCHECKBOX Substantially Were you feeling the effects of the alcohol while driving the vehicle?  FORMCHECKBOX No  FORMCHECKBOX Slightly  FORMCHECKBOX Moderately  FORMCHECKBOX Substantially Have you been convicted of Driving Under the Influence in VT or any other State?  FORMCHECKBOX  No  FORMCHECKBOX  Yes Are you currently on Probation?  FORMCHECKBOX No  FORMCHECKBOX Yes Are you currently on Conditions of Release?  FORMCHECKBOX No  FORMCHECKBOX Yes OTHER QUESTIONS/ANSWERS (Re: DUI or any other offenseS involved) use supplemental page. DUI AFFIDAVIT Page 3 of 4 Revised 8/06 8. IMPLIED CONSENT (Check as read).  FORMCHECKBOX  I am a law enforcement officer of the State of Vermont.  FORMCHECKBOX  I have grounds to believe that you have operated, attempted to operate, or been in actual physical control of a vehicle on a public highway while under the influence of intoxicating liquor, or drugs, or both.   FORMCHECKBOX   FORMCHECKBOX  Vermont law authorizes me, as a law enforcement officer, to request an evidentiary test to determine whether you are under the influence of alcohol or other drugs. Before you decide, I will explain your rights.  FORMCHECKBOX  If you submit to an evidentiary test, you have the right to have additional tests administered at your own expense by someone of your own choosing. The results will be sent only to you or your lawyer. At this time, I am also providing you with a list of facilities in this area that are available to you for drawing a sample of your blood.  FORMCHECKBOX  In addition, if you submit to an evidentiary test administered with an infrared device, following your receipt of the results of that test, you have a right to a second evidentiary test administered by me using the infrared device.  FORMCHECKBOX  If the results of the evidentiary test indicate that you are under the influence of alcohol, you will be subject to criminal charges and your license or privilege to operate a motor vehicle will be suspended for at least 90 days.  FORMCHECKBOX  If you refuse to provide an evidentiary test, and if you have been previously convicted of Driving Under the Influence of intoxicants (DUI/DWI) in Vermont under Title 23 V.S.A. Section 1201 or in any other jurisdiction which prohibited operating, attempting to operate, or being in actual physical control of a motor vehicle on a highway while under the influence of intoxicating liquor or drugs, or both, or while having .08 percent or more by weight of alcohol in the persons blood or an alcohol concentration of .08 or more, you may be charged with the crime of criminal refusal.  FORMCHECKBOX  If you refuse to provide an evidentiary test and you have been involved in an accident/collision resulting in serious bodily injury or death of another, you may be charged with the crime of criminal refusal.  FORMCHECKBOX  If you refuse to provide an evidentiary test, your refusal may be offered into evidence against you at trial.   FORMCHECKBOX   FORMCHECKBOX  Your privilege to drive shall be suspended for at least six months if you refuse the evidentiary test and the court finds my request is reasonable.  FORMCHECKBOX  You have the right to talk with a lawyer before deciding whether or not to submit to an evidentiary test. If you want a lawyer, a Public Defender will be contacted for you at the states expense, regardless of your income, or an attempt will be made to contact an attorney of your choice at your expense.  FORMCHECKBOX  You must decide whether or not to submit to the evidentiary test within a reasonable amount of time and no later than 30 minutes from the time of the initial attempt to contact an attorney, regardless of whether a consultation takes place.  FORMCHECKBOX  Do you understand each of these rights?  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX  Do you want to talk to a lawyer before deciding whether or not to submit to a test?  FORMCHECKBOX  Yes Time of first attempt:__________(per timepiece) # of attempts _____ Lawyer contacted:_____________________ Time Started:___________ Time Finished:______________  FORMCHECKBOX  No _____________________________ _______________________________________ Operators Signature Witness (If operator refuses to sign you MUST contact an attorney unless a recorded waiver is obtained.)  FORMCHECKBOX  Will you give a sample of your breath as evidence  FORMCHECKBOX  Yes  FORMCHECKBOX  No. (IF No, OFFICER SHOULD GO TO Sec. 10) IF YES, 15 Min OBSERVATION PERIOD started at:___________hours Timepiece used:_______________  FORMCHECKBOX  The operator has been observed for 15 uninterrupted minutes during which he/she did not burp, belch, or vomit.  FORMCHECKBOX  Have you burped, belched, or vomited within the last 15 minutes?  FORMCHECKBOX Yes  FORMCHECKBOX No If Yes, restart 15 min. observation. Restarted at:_____________hrs. (per timepiece)  FORMCHECKBOX  Your result is ____________% at __________ per DM clock AND ____________(per timepiece) date ___________________. If result is INVALID, officer should rerun evidentiary test by replacing mouthpiece, then RE-STARTING NEW 15 MIN. OBSERVATION period. Restarted at: ___________hrs. (per DM Clock)  FORMCHECKBOX  Your result is ____________% at __________ per DM clock AND ____________(per timepiece) date ___________________.  FORMCHECKBOX  Do you want a second infrared test NOW?  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  I administered the operators DataMaster breath test in accordance with my training and certification. The evidentiary ticket(s) is (are) incorporated by reference into this affidavit. DUI AFFIDAVIT INFRARED Page 4 of 4 Revised 8/06 9. READ THE APPROPRIATE ALTERNATIVE TO OPERATOR  FORMCHECKBOX  A. Since you are being released, if you wish additional tests, to be paid for at your own expense, you will have to make your own arrangements. Do you intend to obtain additional tests?  FORMCHECKBOX Yes FORMCHECKBOX No Test Kit Provided  FORMCHECKBOX Yes FORMCHECKBOX  No   FORMCHECKBOX  B. Because you are being detained for a short period prior to being released, I will make arrangements for you to have an additional test, at your expense, if you so desire. Do you want me to transport you to obtain an additional test?  FORMCHECKBOX Yes  FORMCHECKBOX No Test Kit Provided  FORMCHECKBOX Yes  FORMCHECKBOX No Arrangements: _________________________________________________  FORMCHECKBOX  C. Because you are being lodged, you must tell me now if you want an additional test, at your expense, so that I can make the arrangements. Do you want me to transport you to obtain an additional test?  FORMCHECKBOX Yes  FORMCHECKBOX No 10. STATUS OF OPERATOR:  FORMCHECKBOX  Inquired as to the operators current address and informed him/her that information is required for future mailings Mailing Address__________________________________ Residential Address_______________________________________ Is operator on active duty, or scheduled to go on active duty, in the Armed Forces?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, Command Unit, Service Branch, and Service #__________________________________________________________________ Operator identified by  FORMCHECKBOX  License____________________  FORMCHECKBOX Other I.D.________________  FORMCHECKBOX Picture I.D.  FORMCHECKBOX Citation  FORMCHECKBOX Lodged  FORMCHECKBOX Released without Citation  FORMCHECKBOX  Complaint #_________  FORMCHECKBOX Other____________ 11. DISCLOSURE OF EVIDENCE: A. OFFICERS OBSERVATIONS OF OPERATOR Attitude  FORMCHECKBOX Excited  FORMCHECKBOX Talkative  FORMCHECKBOX Indifferent  FORMCHECKBOX Profane  FORMCHECKBOX Combative  FORMCHECKBOX Insulting  FORMCHECKBOX Cocky  FORMCHECKBOX Cooperative  FORMCHECKBOX Polite  FORMCHECKBOX Mood Swings Other:__________________________________________________________________________________ Unusual Actions  FORMCHECKBOX Hiccuping  FORMCHECKBOX Belching  FORMCHECKBOX Vomiting  FORMCHECKBOX Fighting  FORMCHECKBOX Laughing B. MOTOR VEHICLE RECORD & DUI CONVICTIONS The DMV RECORD of Operator is attached and incorporated by reference as if fully set forth herein. Record discloses prior DUI Convictions:  FORMCHECKBOX No  FORMCHECKBOX Yes: dates of prior DUI conviction(s): C. RECORDING: Is there a separate audiotape?  FORMCHECKBOX Yes  FORMCHECKBOX No Video: Cruiser  FORMCHECKBOX Yes  FORMCHECKBOX No DUI Processing Room  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX Other:__________________ D. WITNESSES (Passengers / other persons) Name________________________ Address_______________________________________________________ Phone #______________________  FORMCHECKBOX Passenger  FORMCHECKBOX Other Describe Condition: Statement obtained:  FORMCHECKBOX Yes  FORMCHECKBOX No  FORMCHECKBOX Other witnesses listed on separate page 12. DISPOSITION: Operator released to: Name/Address:___________________________________Phone #:_____________________;or Operator taken to:__________________________________________________Phone #:______________________ Acknowledged operator is impaired  FORMCHECKBOX No  FORMCHECKBOX Yes:  FORMCHECKBOX Slight  FORMCHECKBOX Extreme  FORMCHECKBOX Other____________________________ Signature:____________________________________________________________________ Date & Time processing completed: ___/___/___ ____________ per timepiece. Disposition of operators vehicle: ______________________Condition of operators vehicle _________________ VIN of operators Vehicle ________________________________________________________________________ Name of Registered Owner(s) __________________________ Address _____________________________________ Being duly sworn and on oath, I hereby certify that the information contained in this form has been accurately recorded and accurately describes my observations of the actions and statements of the operator identified on page one. ______________________________________ __________ Affiant Date Subscribed and sworn before me this _____ day of ______________ _____________________________________ Notary Public IF OFFICER DID NOT OBSERVE THE DRIVING (whether accident or not) ASK: Did you drink any alcoholic beverage after driving? No / Yes: How many? __________ (FATAL/SERIOUS INJURY ONLY) I have probable cause to believe that you are the surviving operator of a motor vehicle involved in an accident or collision resulting in death or serious bodily injury to another person. I have reasonable grounds to believe that you have some amount of alcohol or other drug in your system. (FATAL/SERIOUS INJURY ONLY) If you refuse to provide an evidentiary test and you have been involved in an accident/collision resulting in serious bodily injury or death to another, the court may issue a search warrant and order you to submit to a blood test. Your refusal may be offered into evidence against you at trial, whether or not a search warrant is sought, and the results of any blood test ordered by the court may be offered into evidence against you at trial. If, at the completion of processing, the operator, after reasonable efforts, is unable to arrange transportation necessary to obtain an additional test and the operator wants a test, the officer must arrange to provide transportation to a facility that will administer the test. 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