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Get Alcohol Influence Report Form 2001-2024

- ALCOHOL INFLUENCE REPORT FORM type name of police department here Defendant First name Age Initial Sex Last name Weight Eyes Case Number Sequential File No. Arrested by CHEMICAL BREATH TEST INFORMATION Instrument Breathalyzer Model 900 Instrument Serial Number Ampoule Control Lot Number Purge Results Dominator Albreath Samples Taken Date / Time Blood Alcohol Test 1 Test 2 Test 3 Test 4 BREATHALYZER CHECK LIST - N.J.A. C. 13 51-3. 6 a 2 Mark all applicable boxes with an X or a check mark. Set Up Phase TESTS N/A Verify Power switch is turned On. If the power switch is in the Off position turn the switch On. Preparation Phase Instrument temperature Verified temperature thermometer reached 50 C plus or minus 3 C. Reference Ampoule Gauged Inserted in left hand holder. Test Ampoule Gauged Opened Verified volume Inserted in right hand holder. Bubbler Inserted into test ampoule Connected to outlet. Light turned on Instrument balanced Blood Alcohol Pointer set on Start Line. Purge Phase Turned control knob to the Take position Flushed Turned control knob to the Analyze position* Purge When red empty signal appeared waited 90 seconds Light turned on Instrument balanced* Purge Result Recorded* Analysis Phase New mouthpiece inserted in breath tube. Take Breath Sample Turned control knob to the Take position Took breath sample from defendant Turned control knob to the Analyze position* Date Time Recorded* When red empty signal appeared waited 90 seconds Light turned on Instrument balanced* Breath Test Result Recorded* Second or subsequent breath tests Test ampoule removed properly disposed* Power switch remained On. Return to Step 1 start next breath test. Steps marked with an N/A are only performed on the first breath test and do not have to be repeated on any subsequent breath tests. C. 13 51-3. 6 a 2 Mark all applicable boxes with an X or a check mark. Set Up Phase TESTS N/A Verify Power switch is turned On. If the power switch is in the Off position turn the switch On. Preparation Phase Instrument temperature Verified temperature thermometer reached 50 C plus or minus 3 C. If the power switch is in the Off position turn the switch On. Preparation Phase Instrument temperature Verified temperature thermometer reached 50 C plus or minus 3 C. Reference Ampoule Gauged Inserted in left hand holder. Test Ampoule Gauged Opened Verified volume Inserted in right hand holder. Reference Ampoule Gauged Inserted in left hand holder. Test Ampoule Gauged Opened Verified volume Inserted in right hand holder. Bubbler Inserted into test ampoule Connected to outlet. Light turned on Instrument balanced Blood Alcohol Pointer set on Start Line. Bubbler Inserted into test ampoule Connected to outlet. Light turned on Instrument balanced Blood Alcohol Pointer set on Start Line. Purge Phase Turned control knob to the Take position Flushed Turned control knob to the Analyze position* Purge When red empty signal appeared waited 90 seconds Light turned on Instrument balanced* Purge Result Recorded* Analysis Phase New mouthpiece inserted in breath tube.

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