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457200-5715000TENNESSEE BLOOD AND/OR BREATH CONSENT ADVISEMENTPursuant to TCA §55-10-406AGENCY TRACKING NUMBER FORMTEXT ?????AGENCY ORI FORMTEXT ?????AGENCY NAME FORMTEXT ?????OFFICER INFORMATIONOFFICER NAME (Last, First, Middle) FORMTEXT ?????BADGE NO. FORMTEXT ?????RANK FORMTEXT ?????DISTRICT/ZONE FORMTEXT ?????CAR# FORMTEXT ?????MONTH FORMTEXT ?????DAY FORMTEXT ?????YEAR FORMTEXT ?????DAY OF WEEK FORMTEXT ?????TIME FORMTEXT ?????SUBJECT INFORMATIONFIRST NAME FORMTEXT ?????MID INITIAL FORMTEXT ?????LAST NAME FORMTEXT ?????SUFFIX FORMTEXT ?????DATE OF BIRTH FORMTEXT ?????AGE FORMTEXT ?????ADDRESS LINE 1 FORMTEXT ?????ADDRESS LINE 2 FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP CODE FORMTEXT ?????PHONE 1 FORMTEXT ?????PHONE 2 FORMTEXT ?????PHONE 3 FORMTEXT ?????RACE FORMTEXT ?????ETHNICITY FORMTEXT ?????GENDER FORMTEXT ?????SS# FORMTEXT ?????DL# FORMTEXT ?????DL STATE FORMTEXT ?????Are you willing to consent to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing? If you refuse to supply a sample for blood or breath testing, no test will be conducted unless required by law or authorized by a search warrant or exigent circumstances. If you do not consent, the law permits me to apply for a search warrant for a blood and/or breath sample for chemical testing. If you refuse to provide a sample for testing, and the Court finds that you refused, TCA §55-10-407 requires that your license will be suspended for at least one (1) year and up to five (5) years, depending on your driving history. If you refuse, you may be ordered to install and keep an ignition interlock device on your vehicle for one (1) year or more.After being informed that there is probable cause that you have committed a crime which requires me to submit a sample of your FORMCHECKBOX blood FORMCHECKBOX breath for testing, and also having the consequences to such test explained to you, you: FORMCHECKBOX CONSENT TO PROVIDE A SAMPLE FORMCHECKBOX REFUSE TO PROVIDE A SAMPLESubject’s Signature, Date, and Time of SignatureSubject’s Signature, Date, and Time of Signature FORMCHECKBOX I have obtained a search warrant for a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing. FORMCHECKBOX There are recognized exigent circumstances which allow me to obtain a FORMCHECKBOX blood FORMCHECKBOX breath sample from you. FORMCHECKBOX The law requires me to obtain a breath sample from you because there is probable cause to believe you have committed a DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide and you have: FORMCHECKBOX Been involved in a crash resulting in the injury or death of another. FORMCHECKBOX A child under the age of sixteen (16) years in your vehicle. FORMCHECKBOX A prior conviction for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide.You are required by law to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing because of the facts checked above. In this situation, if you intentionally refuse, prevent, or obstruct a blood or breath test and the Court finds you so refused, you are guilty of a class (A) misdemeanor. In addition, if the Court also finds that your license was also suspended or revoked for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide at the time of the alleged offense, the Court may fine you one thousand dollars ($1,000.00) and sentence you to a minimum, mandatory jail or workhouse sentence of five (5) days, day for day, to be served consecutively. The minimum, mandatory sentence cannot be suspended.Breath Test Only: You did not have any foreign matter in your mouth, did not smoke, regurgitate or drink any alcoholic beverage during the twenty minutes you were observed prior to the breath test.Subject’s Signature and Date of SignatureObserving Officer’s Signature and Date of SignatureTESTING INFORMATIONWITNESS (If Any) FORMTEXT ?????LOCATION OF TEST FORMTEXT ?????TEST OR TESTS OTHER THAN BREATH WERE REQUESTED? FORMTEXT ?????RESULTS FORMTEXT ?????BLOOD FORMTEXT ?????BREATH FORMTEXT ?????TIME ADVISED OF RESULTS FORMTEXT ?????SF-0388 (Rev. 7/17)COURTRDA 304457200-5715000TENNESSEE BLOOD AND/OR BREATH CONSENT ADVISEMENTPursuant to TCA §55-10-406AGENCY TRACKING NUMBER FORMTEXT ?????AGENCY ORI FORMTEXT ?????AGENCY NAME FORMTEXT ?????OFFICER INFORMATIONOFFICER NAME (Last, First, Middle) FORMTEXT ?????BADGE NO. FORMTEXT ?????RANK FORMTEXT ?????DISTRICT/ZONE FORMTEXT ?????CAR# FORMTEXT ?????MONTH FORMTEXT ?????DAY FORMTEXT ?????YEAR FORMTEXT ?????DAY OF WEEK FORMTEXT ?????TIME FORMTEXT ?????SUBJECT INFORMATIONFIRST NAME FORMTEXT ?????MID INITIAL FORMTEXT ?????LAST NAME FORMTEXT ?????SUFFIX FORMTEXT ?????DATE OF BIRTH FORMTEXT ?????AGE FORMTEXT ?????ADDRESS LINE 1 FORMTEXT ?????ADDRESS LINE 2 FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP CODE FORMTEXT ?????PHONE 1 FORMTEXT ?????PHONE 2 FORMTEXT ?????PHONE 3 FORMTEXT ?????RACE FORMTEXT ?????ETHNICITY FORMTEXT ?????GENDER FORMTEXT ?????SS# FORMTEXT ?????DL# FORMTEXT ?????DL STATE FORMTEXT ?????Are you willing to consent to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing? If you refuse to supply a sample for blood or breath testing, no test will be conducted unless required by law or authorized by a search warrant or exigent circumstances. If you do not consent, the law permits me to apply for a search warrant for a blood and/or breath sample for chemical testing. If you refuse to provide a sample for testing, and the Court finds that you refused, TCA §55-10-407 requires that your license will be suspended for at least one (1) year and up to five (5) years, depending on your driving history. If you refuse, you may be ordered to install and keep an ignition interlock device on your vehicle for one (1) year or more.After being informed that there is probable cause that you have committed a crime which requires me to submit a sample of your FORMCHECKBOX blood FORMCHECKBOX breath for testing, and also having the consequences to such test explained to you, you: FORMCHECKBOX CONSENT TO PROVIDE A SAMPLE FORMCHECKBOX REFUSE TO PROVIDE A SAMPLESubject’s Signature, Date, and Time of SignatureSubject’s Signature, Date, and Time of Signature FORMCHECKBOX I have obtained a search warrant for a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing. FORMCHECKBOX There are recognized exigent circumstances which allow me to obtain a FORMCHECKBOX blood FORMCHECKBOX breath sample from you. FORMCHECKBOX The law requires me to obtain a breath sample from you because there is probable cause to believe you have committed a DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide and you have: FORMCHECKBOX Been involved in a crash resulting in the injury or death of another. FORMCHECKBOX A child under the age of sixteen (16) years in your vehicle. FORMCHECKBOX A prior conviction for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide.You are required by law to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing because of the facts checked above. In this situation, if you intentionally refuse, prevent, or obstruct a blood or breath test and the Court finds you so refused, you are guilty of a class (A) misdemeanor. In addition, if the Court also finds that your license was also suspended or revoked for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide at the time of the alleged offense, the Court may fine you one thousand dollars ($1,000.00) and sentence you to a minimum, mandatory jail or workhouse sentence of five (5) days, day for day, to be served consecutively. The minimum, mandatory sentence cannot be suspended.Breath Test Only: You did not have any foreign matter in your mouth, did not smoke, regurgitate or drink any alcoholic beverage during the twenty minutes you were observed prior to the breath test.Subject’s Signature and Date of SignatureObserving Officer’s Signature and Date of SignatureTESTING INFORMATIONWITNESS (If Any) FORMTEXT ?????LOCATION OF TEST FORMTEXT ?????TEST OR TESTS OTHER THAN BREATH WERE REQUESTED? FORMTEXT ?????RESULTS FORMTEXT ?????BLOOD FORMTEXT ?????BREATH FORMTEXT ?????TIME ADVISED OF RESULTS FORMTEXT ?????SF-0388 (Rev. 7/17)DISTRICT HEADQUARTERSRDA 304457200-5715000TENNESSEE BLOOD AND/OR BREATH CONSENT ADVISEMENTPursuant to TCA §55-10-406AGENCY TRACKING NUMBER FORMTEXT ?????AGENCY ORI FORMTEXT ?????AGENCY NAME FORMTEXT ?????OFFICER INFORMATIONOFFICER NAME (Last, First, Middle) FORMTEXT ?????BADGE NO. FORMTEXT ?????RANK FORMTEXT ?????DISTRICT/ZONE FORMTEXT ?????CAR# FORMTEXT ?????MONTH FORMTEXT ?????DAY FORMTEXT ?????YEAR FORMTEXT ?????DAY OF WEEK FORMTEXT ?????TIME FORMTEXT ?????SUBJECT INFORMATIONFIRST NAME FORMTEXT ?????MID INITIAL FORMTEXT ?????LAST NAME FORMTEXT ?????SUFFIX FORMTEXT ?????DATE OF BIRTH FORMTEXT ?????AGE FORMTEXT ?????ADDRESS LINE 1 FORMTEXT ?????ADDRESS LINE 2 FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP CODE FORMTEXT ?????PHONE 1 FORMTEXT ?????PHONE 2 FORMTEXT ?????PHONE 3 FORMTEXT ?????RACE FORMTEXT ?????ETHNICITY FORMTEXT ?????GENDER FORMTEXT ?????SS# FORMTEXT ?????DL# FORMTEXT ?????DL STATE FORMTEXT ?????Are you willing to consent to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing? If you refuse to supply a sample for blood or breath testing, no test will be conducted unless required by law or authorized by a search warrant or exigent circumstances. If you do not consent, the law permits me to apply for a search warrant for a blood and/or breath sample for chemical testing. If you refuse to provide a sample for testing, and the Court finds that you refused, TCA §55-10-407 requires that your license will be suspended for at least one (1) year and up to five (5) years, depending on your driving history. If you refuse, you may be ordered to install and keep an ignition interlock device on your vehicle for one (1) year or more.After being informed that there is probable cause that you have committed a crime which requires me to submit a sample of your FORMCHECKBOX blood FORMCHECKBOX breath for testing, and also having the consequences to such test explained to you, you: FORMCHECKBOX CONSENT TO PROVIDE A SAMPLE FORMCHECKBOX REFUSE TO PROVIDE A SAMPLESubject’s Signature, Date, and Time of SignatureSubject’s Signature, Date, and Time of Signature FORMCHECKBOX I have obtained a search warrant for a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing. FORMCHECKBOX There are recognized exigent circumstances which allow me to obtain a FORMCHECKBOX blood FORMCHECKBOX breath sample from you. FORMCHECKBOX The law requires me to obtain a breath sample from you because there is probable cause to believe you have committed a DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide and you have: FORMCHECKBOX Been involved in a crash resulting in the injury or death of another. FORMCHECKBOX A child under the age of sixteen (16) years in your vehicle. FORMCHECKBOX A prior conviction for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide.You are required by law to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing because of the facts checked above. In this situation, if you intentionally refuse, prevent, or obstruct a blood or breath test and the Court finds you so refused, you are guilty of a class (A) misdemeanor. In addition, if the Court also finds that your license was also suspended or revoked for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide at the time of the alleged offense, the Court may fine you one thousand dollars ($1,000.00) and sentence you to a minimum, mandatory jail or workhouse sentence of five (5) days, day for day, to be served consecutively. The minimum, mandatory sentence cannot be suspended.Breath Test Only: You did not have any foreign matter in your mouth, did not smoke, regurgitate or drink any alcoholic beverage during the twenty minutes you were observed prior to the breath test.Subject’s Signature and Date of SignatureObserving Officer’s Signature and Date of SignatureTESTING INFORMATIONWITNESS (If Any) FORMTEXT ?????LOCATION OF TEST FORMTEXT ?????TEST OR TESTS OTHER THAN BREATH WERE REQUESTED? FORMTEXT ?????RESULTS FORMTEXT ?????BLOOD FORMTEXT ?????BREATH FORMTEXT ?????TIME ADVISED OF RESULTS FORMTEXT ?????SF-0388 (Rev. 7/17)OFFICERRDA 304457200-5715000TENNESSEE BLOOD AND/OR BREATH CONSENT ADVISEMENTPursuant to TCA §55-10-406AGENCY TRACKING NUMBER FORMTEXT ?????AGENCY ORI FORMTEXT ?????AGENCY NAME FORMTEXT ?????OFFICER INFORMATIONOFFICER NAME (Last, First, Middle) FORMTEXT ?????BADGE NO. FORMTEXT ?????RANK FORMTEXT ?????DISTRICT/ZONE FORMTEXT ?????CAR# FORMTEXT ?????MONTH FORMTEXT ?????DAY FORMTEXT ?????YEAR FORMTEXT ?????DAY OF WEEK FORMTEXT ?????TIME FORMTEXT ?????SUBJECT INFORMATIONFIRST NAME FORMTEXT ?????MID INITIAL FORMTEXT ?????LAST NAME FORMTEXT ?????SUFFIX FORMTEXT ?????DATE OF BIRTH FORMTEXT ?????AGE FORMTEXT ?????ADDRESS LINE 1 FORMTEXT ?????ADDRESS LINE 2 FORMTEXT ?????CITY FORMTEXT ?????STATE FORMTEXT ?????ZIP CODE FORMTEXT ?????PHONE 1 FORMTEXT ?????PHONE 2 FORMTEXT ?????PHONE 3 FORMTEXT ?????RACE FORMTEXT ?????ETHNICITY FORMTEXT ?????GENDER FORMTEXT ?????SS# FORMTEXT ?????DL# FORMTEXT ?????DL STATE FORMTEXT ?????Are you willing to consent to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing? If you refuse to supply a sample for blood or breath testing, no test will be conducted unless required by law or authorized by a search warrant or exigent circumstances. If you do not consent, the law permits me to apply for a search warrant for a blood and/or breath sample for chemical testing. If you refuse to provide a sample for testing, and the Court finds that you refused, TCA §55-10-407 requires that your license will be suspended for at least one (1) year and up to five (5) years, depending on your driving history. If you refuse, you may be ordered to install and keep an ignition interlock device on your vehicle for one (1) year or more.After being informed that there is probable cause that you have committed a crime which requires me to submit a sample of your FORMCHECKBOX blood FORMCHECKBOX breath for testing, and also having the consequences to such test explained to you, you: FORMCHECKBOX CONSENT TO PROVIDE A SAMPLE FORMCHECKBOX REFUSE TO PROVIDE A SAMPLESubject’s Signature, Date, and Time of SignatureSubject’s Signature, Date, and Time of Signature FORMCHECKBOX I have obtained a search warrant for a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing. FORMCHECKBOX There are recognized exigent circumstances which allow me to obtain a FORMCHECKBOX blood FORMCHECKBOX breath sample from you. FORMCHECKBOX The law requires me to obtain a breath sample from you because there is probable cause to believe you have committed a DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide and you have: FORMCHECKBOX Been involved in a crash resulting in the injury or death of another. FORMCHECKBOX A child under the age of sixteen (16) years in your vehicle. FORMCHECKBOX A prior conviction for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide.You are required by law to provide a FORMCHECKBOX blood FORMCHECKBOX breath sample for chemical testing because of the facts checked above. In this situation, if you intentionally refuse, prevent, or obstruct a blood or breath test and the Court finds you so refused, you are guilty of a class (A) misdemeanor. In addition, if the Court also finds that your license was also suspended or revoked for DUI, Vehicular Assault, Aggravated Vehicular Assault, Vehicular Homicide, or Aggravated Vehicular Homicide at the time of the alleged offense, the Court may fine you one thousand dollars ($1,000.00) and sentence you to a minimum, mandatory jail or workhouse sentence of five (5) days, day for day, to be served consecutively. The minimum, mandatory sentence cannot be suspended.Breath Test Only: You did not have any foreign matter in your mouth, did not smoke, regurgitate or drink any alcoholic beverage during the twenty minutes you were observed prior to the breath test.Subject’s Signature and Date of SignatureObserving Officer’s Signature and Date of SignatureTESTING INFORMATIONWITNESS (If Any) FORMTEXT ?????LOCATION OF TEST FORMTEXT ?????TEST OR TESTS OTHER THAN BREATH WERE REQUESTED? FORMTEXT ?????RESULTS FORMTEXT ?????BLOOD FORMTEXT ?????BREATH FORMTEXT ?????TIME ADVISED OF RESULTS FORMTEXT ?????SF-0388 (Rev. 7/17)PERSON ARRESTEDRDA 304 ................
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