Drug Driving Calculator Drug Driving Form Name* First Last Email* Telephone Number* What type of specimen did you provide?Swab onlyBloodUrineFail to provideDrug tested positive for Benzoylecgonine Clonazepam Cocaine Delta-9-Tetrahydrocannabinol (cannabis) Diazepam Flunitrazepam Ketamine Lorazepam Lysergic Acid Diethylamide Methadone Methylamphetamine Methadone Lysergic Acid Diethylamide Amphetamine Other Test given at road side (tick all those that apply) Pupillary Modified Romberg Balance test Walk and turn test One leg stand test Finger to nose test Were you taken to a police station?YesNoDid police clearly explain your rightsYesNoUnsure you understood them fullyDid police explain in detail the process of taking a specimen of blood from you by a health care professional?YesNoDid you receive a sample of blood to be tested for analysis?YesNoDid you take drugs on the day in questionYesNoHave you been convicted of any of the following offencesCausing death by dangerous or careless driving when under the influence of drink or drugsNoIn the last 3 yearsIn the last 10 yearsDriving or attempting to drive while unfit through drink or drugsNoIn the last 3 yearsIn the last 10 yearsDriving or attempting to drive with excess alcoholNoIn the last 3 yearsIn the last 10 yearsFailing to provide a sampleNoIn the last 3 yearsIn the last 10 yearsAggregating CircumstancesWhere you driving an HGV, LGV, PSV etc..? No Yes Were the weather conditions or road conditions poor? No Yes Were you carrying passengers? No Yes Is there any evidence of an unacceptable standard of driving? No Yes Were you involved in an accident? No Yes Was there a high level of traffic or pedestrian activity? No Yes Did you have full UK driving licence AND valid policy of insurance in place? No Yes
