DI-177_Breath_Blood_Urine_Test_Report_528900_7 (Printer Proof).pdf

DI-177 (01/15) By the Authority of P.A. 300 of 1949 as amended

BREATH, BLOOD, URINE TEST REPORT

h MALE h FEMALE

ADDRESS (Number & Street) MICHIGAN DRIVER’S LICENSE NUMBER

CITY STATE ZIP OTHER STATE DRIVER’S LICENSE NUMBER STATE

HEIGHT WEIGHT EYE COLOR HAIR COLOR

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MMDDYY) MILITARY TIME INCIDENT DATE (MMDDYY) MILITARY TIME

COUNTY (Of Arrest) CITY OR TOWNSHIP (Of Arrest) CO/CTY/TWP CODE

Accident? h YES h NO

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME (Only If Not Listed Above And Necessary For Hearing) BADGE NUMBER ORI NUMBER

You have been arrested for a crime described in section 625c of the Michigan Vehicle Code and submitted to a chemical test which revealed an unlawful alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination, or have a blood or urine test pending.

This temporary driving permit is valid only if you have a valid Michigan driver’s license. If your license was restricted, this permit grants the same restrictions. This permit grants you the same CDL and/or endorsements that are on your Michigan license. You may not apply for a replacement photo license.

This permit is to be used until the criminal charges against you are dismissed or until you are acquitted, or your license or permit is suspended, restricted, or revoked for a conviction. [MCL 257.625g(3)]

Michigan driver’s YES NO Michigan driver’s YES NO YES NO

on date of arrest h h h h h h h h h

License Permit A B C H N X P T CDL restrictions CY F R Other

CDL h h h h h h h h h h ENDORSEMENT h h h

Officer’s Signature Date (MMDDYY)

*VEHICLE TYPES

Notice to officer: Complete this form when any chemical test is given.

When a voluntary blood or urine test is pending, or in special cases involving an unconscious person where a search warrant has been issued, attach the Michigan driver’s license or permit to the second copy of this form and issue the third copy to the arrested person.

If a chemical test is refused, use the Officer’s Report of Refusal to Submit to Chemical Test form (DI-93).

For all of the above, input arrest data into the LEIN F Breath Screen, even if the driver is licensed out of state. (Do not confiscate the out of state license.)

Officer’s Copy

BTH TEST OPR NO LEIN ENTRY RECORD SEQUENCE NO

I am a peace officer. You are under arrest for the offense of: (Read only the charge that applies)

• Operating a vehicle while visibly impaired due to the consumption of alcoholic liquor, a controlled substance, other intoxicating substance or a combination.

• Operating with any presence of schedule 1 drugs or cocaine.

• Causing the death of another while operating a vehicle while intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Causing serious injury to another while operating a vehicle while intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Operating a vehicle while less than 21 years of age and having any alcohol content.

• Murder resulting from the operation of a motor vehicle.

• Manslaughter resulting from the operation of a motor vehicle.

• Reckless driving causing death.

• Reckless driving causing serious impairment of a body function.

• Moving violation causing death.

• Moving violation causing serious impairment of a body function.

• Refusing a Preliminary Breath Test if arrested while operating a commercial motor vehicle.

• Endangerment (Operating while intoxicated or while visibly impaired with person under age of 16.)

CHEMICAL TEST RIGHTS

Read the rights that follow in their entirety.

I am requesting that you take a chemical test to check for alcohol and/or controlled substances or other intoxicating substances in your body. IF YOU WERE ASKED TO TAKE OR TOOK A PRELIMINARY BREATH

TEST BEFORE YOUR ARREST, YOU MUST STILL TAKE THE TEST I AM OFFERING YOU.

If you refuse to take this chemical test, it will not be given without a court order, but I may seek to obtain such a court order. Your refusal to take this test shall result in the suspension of your operator’s or chauffeur’s license and vehicle group designation or operating privilege, and the addition of six points to your driving record.

After taking my chemical test, you have a right to demand that a person of your own choosing administer a breath, blood, or urine test. You will be given a reasonable opportunity for such a test. You are responsible for obtaining a chemical analysis of a test sample taken by a person of your own choosing.

The results of both chemical tests shall be admissible in a judicial proceeding, and will be considered with other admissible evidence in determining your innocence or guilt.

Will you take a: (Select the appropriate test from the following list) Breath Test? or *Blood Test? or Urine Test?

*MCL 257.625c(2) provides that a person afflicted with hemophilia, diabetes, or a condition requiring the use of an anticoagulant shall not be considered to have given consent to the withdrawal of blood.

DI-177 (01/15)C

h MALE h FEMALE

ADDRESS (Number & Street) MICHIGAN DRIVER’S LICENSE NUMBER

CITY STATE ZIP OTHER STATE DRIVER’S LICENSE NUMBER STATE

HEIGHT WEIGHT EYE COLOR HAIR COLOR

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MMDDYY) MILITARY TIME INCIDENT DATE (MMDDYY) MILITARY TIME

COUNTY (Of Arrest) CITY OR TOWNSHIP (Of Arrest) CO/CTY/TWP CODE

Accident? h YES h NO

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME (Only If Not Listed Above And Necessary For Hearing) BADGE NUMBER ORI NUMBER

You have been arrested for a crime described in section 625c of the Michigan Vehicle Code and submitted to a chemical test which revealed an unlawful alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination, or have a blood or urine test pending.

This temporary driving permit is valid only if you have a valid Michigan driver’s license. If your license was restricted, this permit grants the same restrictions. This permit grants you the same CDL and/or endorsements that are on your Michigan license. You may not apply for a replacement photo license.

This permit is to be used until the criminal charges against you are dismissed or until you are acquitted, or your license or permit is suspended, restricted, or revoked for a conviction. [MCL 257.625g(3)]

Michigan driver’s YES NO Michigan driver’s YES NO YES NO

on date of arrest h h h h h h h h h

License Permit A B C H N X P T CDL restrictions CY F R Other

CDL h h h h h h h h h h ENDORSEMENT h h h

Officer’s Signature Date (MMDDYY)

Notice to officer:

If the alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination is unlawful, destroy the driver’s license or permit and send this form to the driver. If the alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination does not require driver’s license confiscation, return the driver’s license or permit with this form.

After this form is completed, mail it to the arrested person.

Note: This copy can be discarded if a breath test was given.

Driver’s Notice of Blood or Urine Test Result

BTH TEST OPR NO LEIN ENTRY RECORD SEQUENCE NO

You were arrested for operating a vehicle with an unlawful alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination and submitted to a blood or urine test to determine your alcohol content, the presence of a controlled substance or other intoxicating substance,

h Your alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination does not require confiscation of your driver’s license. Your license is being returned to you. Please see attached. This does not affect the criminal charges pending against you.

h MALE h FEMALE

ADDRESS (Number & Street) MICHIGAN DRIVER’S LICENSE NUMBER

CITY STATE ZIP OTHER STATE DRIVER’S LICENSE NUMBER STATE

HEIGHT WEIGHT EYE COLOR HAIR COLOR

h OPERATOR h CHAUFFEUR h MOPED

ARREST DATE (MMDDYY) MILITARY TIME INCIDENT DATE (MMDDYY) MILITARY TIME

COUNTY (Of Arrest) CITY OR TOWNSHIP (Of Arrest) CO/CTY/TWP CODE

Accident? h YES h NO

ARRESTING OFFICER’S NAME BADGE NUMBER ORI NUMBER

BREATH TEST OPERATOR’S NAME (Only If Not Listed Above And Necessary For Hearing) BADGE NUMBER ORI NUMBER

You have been arrested for a crime described in section 625c of the Michigan Vehicle Code and submitted to a chemical test which revealed an unlawful alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination, or have a blood or urine test pending.

This temporary driving permit is valid only if you have a valid Michigan driver’s license. If your license was restricted, this permit grants the same restrictions. This permit grants you the same CDL and/or endorsements that are on your Michigan license. You may not apply for a replacement photo license.

This permit is to be used until the criminal charges against you are dismissed or until you are acquitted, or your license or permit is suspended, restricted, or revoked for a conviction. [MCL 257.625g(3)]

Michigan driver’s YES NO Michigan driver’s YES NO YES NO

on date of arrest h h h h h h h h h

License Permit A B C H N X P T CDL restrictions CY F R Other

CDL h h h h h h h h h h ENDORSEMENT h h h

Officer’s Signature Date (MMDDYY)

Driver’s Copy

BTH TEST OPR NO LEIN ENTRY RECORD SEQUENCE NO

Note to officer:

Use this form only when a test of a Michigan licensed driver reveals an unlawful alcohol content, or the presence of a controlled substance or other intoxicating substance, or any combination, or when a blood or urine test is pending.

MICHIGAN TEMPORARY DRIVING PERMIT

This permit is only valid if you have a valid Michigan driver’s license.

This permit is not valid if you are unlicensed or your license is expired, suspended, revoked or denied.

Carry this permit when driving.

I am a peace officer. You are under arrest for the offense of: (Read only the charge that applies)

• Operating a vehicle while visibly impaired due to the consumption of alcoholic liquor, a controlled substance, other intoxicating substance or a combination.

• Operating with any presence of schedule 1 drugs or cocaine.

• Causing the death of another while operating a vehicle while intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Causing serious injury to another while operating a vehicle while intoxicated, or while visibly impaired by alcoholic liquor, a controlled substance, other intoxicating substance or a combination, or with an unlawful alcohol content.

• Operating a vehicle while less than 21 years of age and having any alcohol content.

• Murder resulting from the operation of a motor vehicle.

• Manslaughter resulting from the operation of a motor vehicle.

• Reckless driving causing death.

• Reckless driving causing serious impairment of a body function.

• Moving violation causing death.

• Moving violation causing serious impairment of a body function.

• Refusing a Preliminary Breath Test if arrested while operating a commercial motor vehicle.

• Endangerment (Operating while intoxicated or while visibly impaired with person under age of 16.)

CHEMICAL TEST RIGHTS

Read the rights that follow in their entirety.

I am requesting that you take a chemical test to check for alcohol and/or controlled substances or other intoxicating substances in your body. IF YOU WERE ASKED TO TAKE OR TOOK A PRELIMINARY BREATH

TEST BEFORE YOUR ARREST, YOU MUST STILL TAKE THE TEST I AM OFFERING YOU.

If you refuse to take this chemical test, it will not be given without a court order, but I may seek to obtain such a court order. Your refusal to take this test shall result in the suspension of your operator’s or chauffeur’s license and vehicle group designation or operating privilege, and the addition of six points to your driving record.

After taking my chemical test, you have a right to demand that a person of your own choosing administer a breath, blood, or urine test. You will be given a reasonable opportunity for such a test. You are responsible for obtaining a chemical analysis of a test sample taken by a person of your own choosing.

The results of both chemical tests shall be admissible in a judicial proceeding, and will be considered with other admissible evidence in determining your innocence or guilt.

Will you take a: (Select the appropriate test from the following list) Breath Test? or *Blood Test? or Urine Test?

*MCL 257.625c(2) provides that a person afflicted with hemophilia, diabetes, or a condition requiring the use of an anticoagulant shall not be considered to have given consent to the withdrawal of blood.

DI-177 (01/15)C

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