DWI education class

BD-1
Name:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Instructor's Name:
Reason you were stopped:

Other
Arrest occurred in what county?
Was a breath test taken?
(If yes, what was it?
(If no, why not?
Was a blood test taken?
(If yes, what was it?
Before my arrest I was,

Other
# hours?
I had been using (check all that apply)

Other
I was with:
During the week days, I tend to drink on (place the number of drinks/ amount of drugs used next to a.m./p.m.):
Monday:
# a.m.
# p.m.
Tuesday:
# a.m.
# p.m.
Wednesday:
# a.m.
# p.m.
Thursday:
# a.m.
# p.m.
Friday:
# a.m.
# p.m.
During the week-ends, I tend to drink (or use drugs) on (place the number of drinks/amount of drugs used next to a.m./p.m.):
Saturday:
# a.m.
# p.m.
Sunday:
# a.m.
# p.m.
Summarize any other comments about your drug/alcohol usage and the events leading up to your arrest below:
Should be Empty: