APPENDIX D: Connecticut Roadside Survey Data Collection Form
Machine #:___ Refused All___
If subject pulled over, check all that apply: Warn__Belt Tckt__ CPS__ Oth Tckt__ FST__ DWI__ Oth Arrest__
Could Not Make Contact with Driver___ (still estimate age, sex, race, passengers, & vehicle type below)
Coming from: |
Headed to: |
# Miles: |
__ Home |
__ Home |
|
|
Ever been through a police checkpoint before? YES NO Day Night
In past six months besides this one? YES NO
Do you favor the use of checkpoints by police to enforce the law against drinking and driving?
YES NO Comments:
Within the past month, have you seen, heard, or read about any special police efforts to enforce the law against drinking and driving? YES NO
If YES, where? TV Radio Newspaper Poster Brochure Other
ZIP Code Where you Live |
Manually Sampled? |
Took Alcohol Test? |
|
YES NO |
YES NO, refused |
Estimate: Get ZIP of subject if arrested—ask officer for ZIP on driver’s license; Get State off plate if REFUSE ALL
Age __ 16-24 |
Sex __ M |
Race __ White Hispanic |
# of Passengers __0 |
Type of vehicle __ Passenger car |
Test #: _____ Press small far right dot for the test # for this person (if took test) and record here.
If DWI arrest, evidentiary BAC test: ____