Defendant (First name) (Initial) (Last name) Case Number Sequential File No.
A
g
eSexWei
g
ht Eyes Arrested by
CHEMICAL BREATH TEST INFORMATION
Instrument: Breathalyzer, Model 900 [ ] Breathalyzer, Model 900A [ ] Dominator Albreath [ ]
Instrument Serial Number Ampoule Control
Lot Number
Pur
g
e
% Results
Samples Taken
Date / Time
Blood Alcohol
% Results
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
[ ] Verify Power switch is turned "On". If the power switch is in the "Off" position, turn the switch "On".
TESTS
#1 #2 #3 #4
Preparation Phase
[ ] [ ] [ ] [ ] 1. Instrument temperature: Verified temperature, thermometer reached 50
C, plus or minus 3 C.
[ ] N/A
*
N/A
*
N/A
*
2. Reference Ampoule: Gauged; Inserted in left hand holder.
[ ] [ ] [ ] [ ] 3. Test Ampoule: Gauged; Opened; Verified volume; Inserted in right hand holder.
[ ] [ ] [ ] [ ] 4. Bubbler: Inserted into test ampoule; Connected to outlet.
[ ] [ ] [ ] [ ] 5. Light turned on; Instrument balanced, Blood Alcohol Pointer set on Start Line.
Purge Phase
[ ] [ ] [ ] [ ] 6. Turned control knob to the "Take" position; Flushed; Turned control knob to the "Analyze" position.
[ ] [ ] [ ] [ ] 7. Purge: When red empty signal appeared, waited 90 seconds; Light turned on; Instrument balanced.
[ ] [ ] [ ] [ ] 8. Purge Result Recorded.
[ ] [ ] [ ] [ ] 9. Blood Alcohol Pointer set on Start Line.
Analysis Phase
[ ] [ ] [ ] [ ] 10. New mouthpiece inserted in breath tube.
[ ] [ ] [ ] [ ] 11. Take Breath Sample: Turned control knob to the "Take" position; Took breath sample from
defendant; Turned control knob to the "Analyze" position.
[ ] [ ] [ ] [ ] 12. Date & Time Recorded.
[ ] [ ] [ ] [ ] 13. When red empty signal appeared, waited 90 seconds; Light turned on; Instrument balanced.
[ ] [ ] [ ] [ ] 14. Breath Test Result Recorded.
Second or subsequent breath tests
[ ] [ ] [ ] [ ] 15. 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.
Breath Test Operator Copy Given to Subject
Rank Signature Badge # Date Time
- ALCOHOL INFLUENCE REPORT FORM
type name of police department here
