Field Sobriety Test Checklist

Field Sobriety Test Checklist
Use this form to record the subject’s sobriety test details, observations, performance, and final assessment.
Subject and Test Context
Subject Name or Identifier
Officer or Assessor Name
Date of Test
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Test
Hour Minutes
AM/PM Option
Location of Test
Reason for Test or Stop
Weather or Environment Conditions
Pre-Test Observations
Speech Clarity
Balance and Stability
Eye Appearance
Odor of Alcohol or Other Substances
Awareness and Orientation
Notable Behavior
Other
Field Sobriety Test Checklist
Walk-and-Turn
Rows Status Walked Correctly Missed Steps Used Arms for Balance Swayed Could Not Complete
Attempt 1
Attempt 2
One-Leg Stand
Rows Status Raised Foot Correctly Swayed Used Arms for Balance Put Foot Down Could Not Complete
Attempt 1
Attempt 2
Horizontal Gaze Observation
Rows Status Smooth Pursuit Distinct Nystagmus Lack of Smoothness Maximum Deviation Onset Before 45 Degrees
Left Eye
Right Eye
Heel-to-Toe Walk
Rows Status Walked Heel-to-Toe Stepped Off Line Missed Heel-to-Toe Used Arms for Balance Could Not Complete
Attempt 1
Attempt 2
Turn-and-Return
Rows Status Turned as Instructed Lost Balance Paused Used Arms for Balance Could Not Complete
Attempt 1
Alphabet Recitation
Rows Status Completed Correctly Skipped Letters Incorrect Sequence Paused Could Not Complete
Attempt 1
Number Counting
Rows Status Completed Correctly Counted Too Fast Lost Count Paused Could Not Complete
Attempt 1
Other Sobriety Check
Rows Status Performed Correctly Partially Completed Failed Could Not Complete
Check 1
Clues and Performance Notes
Number of Clues Observed
Specific Mistakes Observed
Subject Instructions Followed
Need for Retest
Interruption or Stopping Reason
Additional Observations
Final Assessment and Disposition
Overall Assessment Outcome
Level of Impairment Concern
Recommended Next Step
Final Comments
Should be Empty:

Select theme:

Rows	Status	Walked Correctly	Missed Steps	Used Arms for Balance	Swayed	Could Not Complete
Attempt 1
Attempt 2

Rows	Status	Raised Foot Correctly	Swayed	Used Arms for Balance	Put Foot Down	Could Not Complete
Attempt 1
Attempt 2

Rows	Status	Smooth Pursuit	Distinct Nystagmus	Lack of Smoothness	Maximum Deviation	Onset Before 45 Degrees
Left Eye
Right Eye

Rows	Status	Walked Heel-to-Toe	Stepped Off Line	Missed Heel-to-Toe	Used Arms for Balance	Could Not Complete
Attempt 1
Attempt 2

Field Sobriety Test Checklist

Subject and Test Context

Pre-Test Observations

Field Sobriety Test Checklist

Clues and Performance Notes

Final Assessment and Disposition