Section 3.37 Initial Interview (DWI Cases)

• Library: Criminal Practice 2012 Forms

First Conference Questionnaire

[1] Basic Information

Name ____________________________ Age

Birthdate _________________________ Birth Place

Address

Town ____________________________ State

Apartment/Condo/House (circle) Rent/Own (circle)

Home Phone _______________________ Social Security No.

[2] License

Driver’s License No. _________________ State

Restrictions

Date of issue _______________________ Expiration

[3] Employment

Employer

Job title ___________________________ How long

Duties

Annual salary ________________________ Work phone

Prior employment

How long

Any problems with employment?

Use car in employment? Yes/No (circle)

How many miles driven to/from work

How many miles driven at work each week

Comments; To Be Done:

[4] Education?Highest grade completed:

High School ________________________ Year graduated

College ____________________________ Year graduated

Major

Special training

Honors

Comments; To Be Done:

[5] Family

Married/Single/Divorced/Widowed (circle)

Spouse name

Spouse employment

Date of marriage ___________________ How many times married?

Do you spend time with your spouse each day? Yes/No (circle)

If so, how much?

What activities do you and your spouse enjoy doing together?

Does your spouse drink? Yes/No (circle) How much?

Any family member have a problem with alcohol (which one[s])?

Did your parents drink? Yes/No (circle) Which?

Mother’s name ________________________________ Living? Yes/No (circle)

Where?

Employed by

Father’s name ________________________________ Living? Yes/No (circle)

Where?

Employed by

Child’s name:

Age ________________ School

Occupation

Residence

Marital Status

Child’s name:

Age ________________ School

Occupation

Residence

Marital Status

Child’s name:

Age ________________ School

Occupation

Residence

Marital Status

Child’s name:

Age ________________ School

Occupation

Residence

Marital Status

Do you spend time with your children? Yes/No (Circle) How much?

What activities do you and your children like to do together?

Do your children drink?

Brothers and Sisters:

Name

Address

Employer

Spouse

Name

Address

Employer

Spouse

Name

Address

Employer

Spouse

Comments; To Be Done:

[6] Health

Weight ___________________________ Height

General health condition

Any physical disabilities?

Particular Items (Think about these; any problems at all?):

Hearing

Vertigo

Dizziness

Eyes

Glasses ______________________ Contact lenses

Allergies

False teeth

Gum surgery

Gum problem

Walking

Legs

Knees

Feet

Arthritis

Arms

Stomach

Lungs/Breathing

Liver

Bladder/Kidney

Take medication now? Yes/No (circle)

What?

Doctor

How long been taking?

How affects you

Taking medicine when arrested? Yes/No (circle)

What?

Why?

Doctor

How long been taking?

How affects you

Any surgery? If so: what, when, where, and doctor:

Do you have large, medium, or small bladder?

How often do you normally urinate?

While drinking, do you urinate more frequently?

Do you smoke? Yes/No (circle) If yes, how much?

Do you have shortness of breath or any lung problem?

History of mental illness or disorders? Yes/No (circle)

Ever seen a psychiatrist? Yes/No (circle)

Who?

Where?

When?

Result

Ever been advised to see a psychiatrist? Yes/No (circle)

Why?

Comments; To Be Done:

[7] Military

Service? Yes/No (circle) Branch

Date entered _______________________ Discharge Date

Type of discharge ___________________ Rate/Rank

Honors, Recommendations

Special training

When served

Comments; To Be Done:

[8] Habits/hobbies

Favorite form of relaxation

Regular form of hobby

How often

Comments; To Be Done:

[9] Awards/recognition/honors

Describe any

Comments; To Be Done:

[10] Membership

Religious preference

Church membership

Attend regularly? Yes/No (circle) How often?

Offices held

Civic clubs

When a member?

Comments; To Be Done:

[11] Alcohol

Age when initial contact with alcohol

Favorite alcoholic beverage

Do you switch around, depending on mood? Yes/No (circle)

Is there a particular alcoholic beverage you do not drink? Yes/No (circle)

What?

Who do you drink with?

How much does it take for you to feel effects?

How does it affect you?

How much is “too much” for you?

Ever been drunk? Yes/No (circle) When?

How often do you get drunk?

Alcoholics Anonymous? Yes/No (circle)

Problem with alcohol?

How do you know when you’re “drunk”?

Can you “hold your liquor”? Yes/No (circle)

How often do you consume alcohol?

How much do you normally drink when you’re drinking?

How does that quantity usually affect you?

Comments; To Be Done:

[12] Conviction

What effect will a conviction have on you personally?

Will a conviction affect your employment? Yes/No (circle)

How?

Comments; To Be Done:

[13] Events of day of arrest

Date ___________________________ Day of week

Sleep the night before? Yes/No (circle) How long?

How many hours do you normally sleep?

Food intake:

Breakfast: What?

When?

Where?

Lunch: What?

When?

Where?

Dinner: What?

When?

Where?

Activities that day: (work)

What time start?

What time stop?

Driving?

What duties?

After work, describe activities until arrest: (chronological)

On day of arrest, describe what alcohol you had to drink and when (including size and percentage of alcohol):

1st

2nd

3rd

4th

5th

6th

7th

Where did you intend to go before arrested?

Where had you just left?

Describe actions and conversations upon leaving the place where you were:

Where were your keys?

Was the car door locked? Yes/No (circle)

Difficulty putting key in lock? Yes/No (circle)

Different key other than ignition to unlock door? Yes/No (circle)

Where parked?

Parking brake on? Yes/No (circle)

Difficulty putting key in ignition? Yes/No (circle)

Take two hands to engage ignition? Yes/No (circle)

Drive in reverse before you went forward? Yes/No (circle)

Light? On/Off Which way did you turn? Right/Left (circle)

Who...