INFORMATION
Name of sample donor:
Age when tested:	Sex at birth:	Male	Female
Height:	Weight:
Evidential Test Result:	Breath	Blood	Urine
Time of evidential test/sampling:
Time of driving/incident:
Please enclose test printout or certificate of analysis
INSTRUCTIONS TO EXPERT Please complete in FULL. Subsequent revisions may incur additional costs.
Drunk in charge	The next intended time of driving was:
Driving whilst over the prescribed limit	Please calculate the effect of:	Spiked drinks
Post driving drinking
Medications
Please calculate the likely alcohol level at (time): (time):
Alcohol consumed BEFORE driving/incident:
Date	Time	Amount (e.g. 330ml bottle)	Specific Brand/Type and alcohol content (e.g. Smirnoff vodka red, 37.5%)	Tick unwitting consumption
When did drinking cease before driving/incident?
Alcohol consumed AFTER driving/incident:
Date	Time	Amount (e.g. 1 pint)	Specific Brand/Type and alcohol content (e.g. Red wine, brand and % unknown)	Tick unwitting consumption
When did drinking cease before giving an evidential sample?
Food intake throughout day/evening in question
Date	Time	Brief description
Comments

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