CLEAR FORM
DRUG INFLUENCE EVALUATION
EVALUATOR
DRE#
RECORDER/WITNESS:
CRASH
ARRESTING OFFICER'S AGENCY
Fatal
Injury
ARRESTEE'S NAME (LAST, FIRST, MIDDLE)
DOB
DATE EXAMINED/TIME/LOCATION
BREATH RESULTS:
Property
None
SEX
RACE
Yes
CHEMICAL TEST
Urine
INSTRUMENT #
WHAT HAVE YOU EATEN TODAY? WHEN?
No
ARRESTING OFFICER (NAME, ID#)
REFUSED
RESULTS
MIRANDA WARNING GIVEN:
EVALUATOR'S AGENCY
ROLLING LOG#
Blood
WHAT HAVE YOU BEEN DRINKING? HOW MUCH?
Test or tests refused
TIME OF LAST DRINK?
BY:
WHEN DID YOU LAST SLEEP? HOW LONG?
TIME NOW?/ACTUAL
ARE YOU SICK OR INJURED?
Yes
DO YOU TAKE INSULIN?
Yes
Yes
No
CORRECTIVE LENSES:
PUPIL SIZE:
Yes
No
COORDINATION
BREATH ODOR:
FACE:
Hard
Soft
None
BLINDNESS:
Normal
Bloodshot
Watery
Equal
Yes
HGN
3.
/
/
/
LEFT EYE
None
Reddened Conjunctiva
No
RIGHT EYE
TRACKING:
Left
Right
Yes
CONVERGENCE:
Normal
R
ANGLE OF ONSET
WALK AND TURN TEST
Droopy
ONE LEG STAND
MAX. DEVIATION
RIGHT EYE
Unequal
EYELIDS:
No
LACK OF SMOOTH PURSUIT
ROMBERG BALANCE
APPROX.
APPROX.
Equal
ABLE TO FOLLOW STIMULUS:
VERTICAL NYSTAGMUS:
Unequal (explain)
2.
No
ATTITUDE
EYES:
Contacts, if so
PULSE & TIME:
1.
No
ARE YOU UNDER THE CARE OF A DOCTOR OR DENTIST?
No
SPEECH:
Glasses
Yes
DO YOU HAVE ANY PHYSICAL DEFECT?
ARE YOU TAKING ANY MEDICATION OR DRUGS?
Yes
ARE YOU DIABETIC OR EPILEPTIC?
No
LEFT EYE
L
L
R
CANNOT KEEP BALANCE
L
STARTS TOO SOON
1st NINE
R
2nd NINE
SWAYS WHILE BALANCING
STOPS WALKING
USES ARMS TO BALANCE
MISSES HEEL-TOE
HOPPING
STEPS OFF LINE
RAISES ARMS
PUTS FOOT DOWN
ACTUAL STEPS TAKEN
INTERNAL CLOCK
ESTIMATED AS
30 SEC.
DESCRIBE TURN
TYPE OF FOOTWEAR:
CANNOT DO TEST (EXPLAIN)
PUPIL SIZE
ROOM LIGHT
DARKNESS
5.0 - 8.5
DIRECT
2.0 - 4.5
LEFT EYE
NASAL AREA
ORAL CAVITY
RIGHT EYE
REBOUND DILATION
Yes
REACTION TO LIGHT
No
RIGHT ARM
BLOOD PRESSURE
MUSCLE TONE:
NORMAL
LEFT ARM
TEMP
FLACCID
RIGID
COMMENTS:
WHAT MEDICINE OR DRUG HAVE YOU BEEN USING?
DATE/TIME OF ARREST
HOW MUCH?
TIME OF DRE WAS NOTIFIED
OFFICER'S SIGNATURE
OPINION OF EVALUATOR:
S.P. 444 (Rev. 04/09)
TIME OF USE?
EVALUATION START TIME
DRE#:
WHERE WERE THE DRUGS USED? (Location)
EVALUATION COMPLETION TIME
PRECINCT/STATION:
REVIEWED/APPROVED BY/DATE:
RULE OUT
ALCOHOL
CNS STIMULANT
DISSOCIATIVE ANESTHETIC
INHALANT
MEDICAL
CNS DEPRESSANT
HALLUCINOGEN
NARCOTIC ANALGESIC
CANNABIS
STATE OF NEW JERSEY DRUG INFLUENCE EVALUATION CONTINUATION
LOG NUMBER
1. LOCATION
5. INITIAL OBSERVATION
9. SIGNS OF INGESTION
1. LOCATION:
S.P. 444 (04/09)
DRE NUMBER
2. WITNESS
6. MEDICAL PROBLEMS
10. SUSPECT'S STATEMENT
PAGE
OF
ARRESTEE (LAST, FIRST, M.I.)
3. BREATH TEST
7. PSYCHOPHYSICAL
11. OPINION
4. NOTIFICATION/ INTERVIEW ARRESTING OFFICER
8. CLINICAL INDICATORS
12. TOX SAMPLE
13. MISC.
STATE OF NEW JERSEY DRUG INFLUENCE EVALUATION CONTINUATION
LOG NUMBER
1. LOCATION
5. INITIAL OBSERVATION
9. SIGNS OF INGESTION
1. LOCATION:
S.P. 444 (04/09)
DRE NUMBER
2. WITNESS
6. MEDICAL PROBLEMS
10. SUSPECT'S STATEMENT
PAGE
OF
ARRESTEE (LAST, FIRST, M.I.)
3. BREATH TEST
7. PSYCHOPHYSICAL
11. OPINION
4. NOTIFICATION/ INTERVIEW ARRESTING OFFICER
8. CLINICAL INDICATORS
12. TOX SAMPLE
13. MISC.