Historical source form revised April 2020. Keep the original advisement language intact for comparison, but verify current Vermont law and agency-approved scripts before use. Only record responses actually obtained; never auto-attest to statements not performed.
Page 1 of 4 — Vehicle operation, observations, SFST CASE#
NOW COMES
cause to believe that
2. On
2. On __________________ at
physical control, of a (year/make/model)
trol, of a (year/make/model) _____________________________, bearing registration
on a public highway known as
on a public highway known as _______________________ in the town/city of
of
My observations of the defendant’s operation
Select… Officer observed operation
Although I did not observe operation
Select… Officer did not observe operation
described vehicle at
Odor of intoxicants
Select… Strong Moderate Faint None
Have you consumed any alcoholic beverages?
Select… Yes No Not answered / not applicable
No Yes: How many?
Did you drink any alcoholic beverages after driving? No / Yes: How many?
Did you drink any alcoholic beverages after driving?
Select… Yes No Not answered / not applicable
How much did you drink in the 30 minutes before you stopped driving?
3. What time was your last drink? How much did you drink in the 30 minutes before you stopped driving? __________
4. How much, if anything, have you had to drink in the last 30 minutes?
Have you consumed any drugs or medications?
Select… Yes No Not answered / not applicable
Difficulty getting out of vehicle?
Select… Yes No Not answered / not applicable
Alcoholic containers in vehicle? No Yes #
Alcoholic containers in vehicle? No Yes #_________ Types:
Alcoholic containers in vehicle?
Select… No Yes
Alcoholic containers in vehicle? No Yes #_________ Types: ________________________ Full Empty None
Is there any reason that the operator cannot perform these exercises?
Select… Yes No Not answered / not applicable
orm these exercises? No Yes: Explanation (e.g. roadway, health, etc.):
Onset of distinct jerkiness prior to 45
Loses balance while turning/turns incorrectly
Stand Uses arms to balance (raises arms more than 6 inches)
Internal Clock
Officer’s opinion of Impairment
Select… None Slight Moderate Substantial Extreme
PBT Result
PBT Result _________% BAC at
PBT Result _________% BAC at _________Hrs. Model:
PBT Result _________% BAC at _________Hrs. Model:___________ Serial #
Additional handwritten/checkbox facts, original page 1
Page 2 of 4 — Rights, waiver and interview TIME OBSERVATION OF OPERATOR STARTED:
TIME OBSERVATION OF OPERATOR STARTED: ____Hrs. Timepiece used:
Advisement: You have the right to remain silent.
Select… Read Not read Not applicable
Advisement: Anything you say can and will be used against you in a court of law.
Select… Read Not read Not applicable
Advisement: You have the right to talk to a lawyer before questioning and to have a lawyer present wit
Select… Read Not read Not applicable
Advisement: If you cannot afford to hire a lawyer, one will be appointed to represent you at public ex
Select… Read Not read Not applicable
Advisement: In Vermont, that is called a public defender.
Select… Read Not read Not applicable
Advisement: If you decide to answer questions, you may stop the questioning at any time.
Select… Read Not read Not applicable
Do you understand each of these rights I have explained to you? Reply: Yes No
Do you understand each of these rights I have explained to you?
Select… Yes No Not answered / not applicable
Do you want to talk to me now? Reply: Yes No
Do you want to talk to me now?
Select… Yes No Not answered / not applicable
been made to me.
__________________________________
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? Beer Liquor Wine – Specific type (brand/name of drink)
How many drinks of each kind did you have?
What time did you start drinking? What time did you stop drinking?
How much if anything did you drink in the 30 minutes before you stopped driving?
Who were you drinking with? (obtain names)
Where (specific location) were you drinking?
Are your tired?
Select… Yes No Not answered / not applicable
Are you ill?
Select… Yes No Not answered / not applicable
Do you have any physical handicaps?
Select… Yes No Not answered / not applicable
Do you limp?
Select… Yes No Not answered / not applicable
Do you have diabetes?
Select… Yes No Not answered / not applicable
Taking insulin?
Select… Yes No Not answered / not applicable
Do you have epilepsy?
Select… Yes No Not answered / not applicable
Have you been injured lately?
Select… Yes No Not answered / not applicable
Do you wear glasses?
Select… Yes No Not answered / not applicable
Do you wear contact lenses?
Select… Yes No Not answered / not applicable
In the last 24 hours have you taken any medications or drugs?
Select… Yes No Not answered / not applicable
Were the drugs/medications affecting your driving?
Select… No Slightly Moderately Substantially
Were the drugs/medications affecting your driving? No Slightly Moderately Substantially
Please describe what drug/medication and the dosage/amount consumed?
Are you under the influence of drugs right now?
Select… No Slightly Moderately Substantially
Are you under the influence of drugs right now? No Slightly Moderately Substantially
Are you under the influence of alcohol now?
Select… No Slightly Moderately Substantially
Are you under the influence of alcohol now? No Slightly Moderately Substantially
Were you under the influence of drugs while driving
Select… No Slightly Moderately Substantially
Were you under the influence of drugs while driving the vehicle? No Slightly Moderately Substantially
Were you under the influence of alcohol while driving
Select… No Slightly Moderately Substantially
Were you under the influence of alcohol while driving the vehicle? No Slightly Moderately Substantially
Were you feeling the effects of the alcohol
Select… No Slightly Moderately Substantially
Were you feeling the effects of the alcohol while driving the vehicle? No Slightly Moderately Substantially
Were you feeling the effects of the drug(s)
Select… No Slightly Moderately Substantially
Were you feeling the effects of the drug(s) while driving the vehicle? No Slightly Moderately Substantially
Have you been convicted of Driving Under the Influence
Select… Yes No Not answered / not applicable
If YES, where and when?
Are you currently on Probation?
Select… Yes No Not answered / not applicable
Are you currently on Conditions of Release?
Select… Yes No Not answered / not applicable
Additional handwritten/checkbox facts, original page 2
Page 3 of 4 — Implied consent, infrared testing Advisement: I am a law enforcement officer of the State of Vermont.
Select… Read Not read Not applicable
Advisement: I have grounds to believe that you have operated, attempted to operate, or been in actual
Select… Read Not read Not applicable
Advisement: vehicle on a public highway while under the influence of intoxicating liquor, or drugs, or
Select… Read Not read Not applicable
Advisement: (FATAL/SERIOUS INJURY ONLY) I have probable cause to believe that you are the surviving o
Select… Read Not read Not applicable
Advisement: vehicle involved in an accident or collision resulting in death or serious bodily injury t
Select… Read Not read Not applicable
Advisement: grounds to believe that you have some amount of alcohol or other drug in your system.
Select… Read Not read Not applicable
Advisement: Vermont law authorizes me, as a law enforcement officer, to request an evidentiary test to
Select… Read Not read Not applicable
Advisement: influence of alcohol or other drugs. Before you decide, I will explain your rights.
Select… Read Not read Not applicable
Advisement: If you submit to an evidentiary test, you have the right to have additional tests administ
Select… Read Not read Not applicable
Advisement: your own choosing. The results will be sent only to you or your lawyer. At this time, I am
Select… Read Not read Not applicable
Advisement: facilities in this area that are available to you for drawing a sample of your blood.
Select… Read Not read Not applicable
Advisement: In addition, if you submit to an evidentiary test administered with an infrared device, fo
Select… Read Not read Not applicable
Advisement: test, you have a right to a second evidentiary test administered by me using the infrared
Select… Read Not read Not applicable
Advisement: If the results of the evidentiary test indicate that you are under the influence of alcoho
Select… Read Not read Not applicable
Advisement: and your license or privilege to operate a motor vehicle will be suspended for at least 90
Select… Read Not read Not applicable
Advisement: If you refuse to provide an evidentiary test, and if you have been previously convicted of
Select… Read Not read Not applicable
Advisement: Influence of intoxicants (DUI/DWI) in Vermont under Title 23 V.S.A. Section 1201 or in any
Select… Read Not read Not applicable
Advisement: operating, attempting to operate, or being in actual physical control of a motor vehicle o
Select… Read Not read Not applicable
Advisement: intoxicating liquor or drugs, or both, or while having .08 percent or more by weight of al
Select… Read Not read Not applicable
Advisement: concentration of .08 or more, you may be charged with the crime of criminal refusal.
Select… Read Not read Not applicable
Advisement: If you refuse to provide an evidentiary test and you have been involved in an accident/col
Select… Read Not read Not applicable
Advisement: or death of another, you may be charged with the crime of criminal refusal.
Select… Read Not read Not applicable
Advisement: If you refuse to provide an evidentiary breath test, your refusal may be offered into evid
Select… Read Not read Not applicable
Advisement: (FATAL/SERIOUS INJURY ONLY) If you refuse to provide an evidentiary test and you have been
Select… Read Not read Not applicable
Advisement: accident/collision resulting in serious bodily injury or death to another, the court may i
Select… Read Not read Not applicable
Advisement: to a blood test. Your refusal to submit to an evidentiary breath test may be offered into
Select… Read Not read Not applicable
Advisement: search warrant is sought, and the results of any blood test ordered by the court may be of
Select… Read Not read Not applicable
Advisement: Your privilege to drive shall be suspended for at least six months if you refuse the evide
Select… Read Not read Not applicable
Advisement: You have the right to talk with a lawyer before deciding whether or not to submit to an ev
Select… Read Not read Not applicable
Advisement: Public Defender will be contacted for you at the state’s expense, regardless of your incom
Select… Read Not read Not applicable
Advisement: an attorney of your choice at your expense.
Select… Read Not read Not applicable
Advisement: You must decide whether or not to submit to the evidentiary test within a reasonable amoun
Select… Read Not read Not applicable
Advisement: 30 minutes from the time of the initial attempt to contact an attorney, regardless of whet
Select… Read Not read Not applicable
Do you understand each of these rights?
Select… Yes No Not answered / not applicable
Do you want to talk to a lawyer before deciding whether or not to submit to a test?
Select… Yes No Not answered / not applicable
Yes Time of first attempt:
Yes Time of first attempt:__________(per timepiece) # of attempts
Lawyer contacted:
Lawyer contacted:_____________________ Time Started:
Lawyer contacted:_____________________ Time Started:___________ Time Finished:
No
_____________________________
Will you give a sample of your breath as evidence
Select… Yes No Not answered / not applicable
IF YES, 15 Min OBSERVATION PERIOD started at:
IF YES, 15 Min OBSERVATION PERIOD started at:___________hours Timepiece used:
Have you burped, belched, or vomited within the last 15 minutes?
Select… Yes No Not answered / not applicable
If Yes, restart 15 min. observation. Restarted at:
Your result is
Your result is ____________% at
Your result is ____________% at __________ per DMT clock AND
date
OBSERVATION period. Restarted at:
Your result is
Your result is ____________% at
Your result is ____________% at __________ per DMT clock AND
date
Do you want a second infrared test NOW?
Select… Yes No Not answered / not applicable
Additional handwritten/checkbox facts, original page 3
Page 4 of 4 — Additional testing, evidence and disposition Do you intend to obtain additional tests?
Select… Yes No Not answered / not applicable
Test Kit Provided
Select… Yes No Not answered / not applicable
Do you want me to transport you to obtain an additional test?
Select… Yes No Not answered / not applicable
Test Kit Provided Yes No Arrangements:
Test Kit Provided
Select… Yes No Not answered / not applicable
Do you want me to transport you to obtain an additional test?
Select… Yes No Not answered / not applicable
Mailing Address
Mailing Address__________________________________ Residential Address
Is operator on active duty
Select… Yes No Not answered / not applicable
Unit, Service Branch, and Service #
Operator identified by License
Operator identified by License____________________ Other I.D.
Citation Lodged Released without Citation Complaint #
n Lodged Released without Citation Complaint #_________ Other
Record discloses prior DUI Convictions:
Select… Yes No Not answered / not applicable
Is there a separate audiotape?
Select… Yes No Not answered / not applicable
Phone #
Statement obtained:
Select… Yes No Not answered / not applicable
Date & Time processing completed:
Date & Time processing completed: ___/
Date & Time processing completed: ___/___/
Date & Time processing completed: ___/___/___
Entry following:
Subscribed and sworn before me this
Subscribed and sworn before me this ____________ day of
Additional handwritten/checkbox facts, original page 4
Page 1-A — Operation narrative CASE #
NOW COMES
that I have probable cause to believe that
2. On
2. On ___________________ at
physical control, of a
trol, of a _______________________________, on a public highway known as
______________ in the town/city of
______________ in the town/city of ___________ in the county of
bserve operation in this case, I was able to determine that the time of operation was
Although I did not observe operation
Select… Officer did not observe operation
Additional handwritten/checkbox facts, original page 5
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