Failure to Provide Calculator Failing to Provide Form Name* First Last Email* Phone number* Please give the reasons as to why you were unable to provide a blood/urine test (tick those that apply) State of mind Mental health Being able to comprehend the situation and follow instructions Stress Panic attack Depression Anxiety Asthma Cardiovascular diseases Respiratory diseases Shortening of breath/tightening of the chest maybe brought on by a panic attack Fear of needles Prostate disease Bladder infections Urethral disease Urinary retention Incontinence Other – please state Please complete these question if you have ticked any the above multi select boxesHave you ever suffered from these symptoms before?YesNoCan you provide medical evidence / Witnesses to support this?YesNoDid you make the police aware of any condition you have for failing to provide a sample?YesNoUnsureWere you offered an alternative test?Yes - BloodYes - UrineYes - BreathalyserNo
