OUT-OF-STATE PETITIONER ALCOHOL/DRUG EVALUATION UNIFORM REPORT

OUT-OF-STATE PETITIONER ALCOHOL/DRUG EVALUATION UNIFORM REPORT Office of the Secretary of State DEPARTMENT OF ADMINISTRATIVE HEARINGS Additioal forms may be obtaied at www.cyberdriveilliois.com INSTRUCTIONS: Ay DUI offeder makig a out-of-state petitio for restoratio of his/her drivig privileges i Illiois must submit a Alcohol/Drug Evaluatio as part of that process. The evaluatio must be completed by a professioal service provider qualified to evaluate the ature ad extet of the petitioer s past ad curret use of alcohol or other drugs. The idividual or agecy coductig the evaluatio must have the expertise ad be properly licesed ad/or authorized i that state to evaluate ad/or treat alcohol/drug-related problems. It is the resposibility of the petitioer to locate a service provider i the state he/she resides. A service provider may be foud by cosultig the yellow pages i the area telephoe directory or the classified ad sectio of a local ewspaper. May states operate their ow evaluatio/itervetio programs for DUI offeders; therefore, a service provider may be foud by cotactig a state s driver s licesig agecy. NOTE: This form may be used oly by a out-of-state program to coduct a evaluatio. If you choose to retur to Illiois to obtai the required evaluatio, a Illiois-licesed program must use the form provided by the Illiois Departmet of Huma Services, Divisio of Alcoholism ad Substace Abuse. All items o this form must be completed. The iformatio should be typed as illegible documets will delay the applicatio process or result i the deial of the petitioer s applicatio. NOTE: The out-of state service provider may choose to complete his/her ow Alcohol/Drug Evaluatio Form as log as it icludes the iformatio requested i this documet, provided the requested iformatio icreases the petitioer s chaces of beig reistated. PERSONAL: This Alcohol/Drug Evaluatio form reports the ature ad extet of the use of alcohol or drugs ad the resultig recommedatios for the followig petitioer. Name: (Last, First, Middle) Illiois Driver s Licese Number: Address: (Street/City/State/ZIP) Sex: Date of Birth: Home Telephoe Number: Work Telephoe Number: M F / / ( ) ( ) Begiig Date of Evaluatio: Completio Date of Evaluatio: Prited by authority of the State of Illiois. August 2014 1 DAH 00S-1.3 1

All items i the followig sectios must be aswered. If more space is eeded, attach additioal sheets. Whe icludig ay direct-quote statemets, idetify them with quotatio marks. ALCOHOL/DRUG USE HISTORY: 1. Provide a complete ad accurate chroological history of the petitioer s alcohol ad drug use from the oset of use up to ad icludig his/her last alcohol/drug related arrest ad from the last alcohol/drug related arrest through the date of this evaluatio ad/or curret abstiet date. Iclude frequecy, type amout ad duratio of said patters, alog with clear ad complete explaatio for ay variace i said patters. This must iclude frequecy of itoxicatios, ay drug use, ad amouts eeded to become itoxicated. List ay ad all prior attempts at abstiece. Idicate whether mixed driks are sigle shot, doubles or free-poured; beers are 12 ouce, 16 ouce, 24 ouce, 32 ouce or 40 ouce cotaiers; ad glass size i ouces if cosumig wie or mixed driks. Report the petitioer s first itoxicatio ad whether he/she exhibited vivid recall of this evet. Report whe the petitioer first exhibited alcohol/drug-related problems. 2. What additioal symptoms ad/or alcohol/drug-related problems has the petitioer experieced throughout his/her drikig ad other drug use history? a. Missed work... YES NO b. Uder the ifluece of alcohol/drugs durig work... YES NO c. Uder the ifluece of alcohol/drugs before oo... YES NO d. Gulped or seaked driks... YES NO e. Hidde alcohol/drugs i the home from parets or spouse... YES NO f. Experieced memory loss of evets that occurred durig itoxicatio... YES NO g. Passed out... YES NO h. Become sick (headaches, hagovers, upset stomach, vomitig, etc.)... YES NO i. Bee i a fight... YES NO j. Had close frieds or relatives express cocer over drikig/drug use... YES NO k. Set out with thought of havig a social drik but became itoxicated... YES NO l. Lost frieds or had relatioships break up over alcohol/drug use... YES NO m. Felt idigat whe cofroted with possible alcohol/drug problem... YES NO. Felt guilty or ashamed of thigs said or did while drikig/usig drugs... YES NO o. Tried to quit drikig/usig drugs but failed... YES NO p. Experieced extreme persoality chages whe drikig/usig drugs... YES NO q. Noticed icreased tolerace to alcohol or other drugs... YES NO r. Used alcohol to self-medicate chroic pai... YES NO s. Experieced shakes or tremors... YES NO 2

3. If usig the DSM IV criteria to determie the petitioer s classificatio, check the symptoms idetified for Alcohol/Drug Abuse: Recurret substace use resultig i failure to fulfill major role obligatios at work, school or home. Recurret substace use i situatios where it is physically hazardous. Recurret substace-related legal problems. Cotiued substace use despite havig persistet or recurret social or iterpersoal problems caused or exacerbated by the effects of the substace. 4. If usig the DSM IV criteria to determie the petitioer s classificatio, check the symptoms idetified for Alcohol/Drug Depedecy: Tolerace Either a eed for markedly icreased amouts of the substace to achieve itoxicatio or the desired effect, or a markedly dimiished effect with cotiued use of the same amout of the substace. Withdrawal As maifested by either the characteristic withdrawal sydrome for the substace, or the same or closelyrelated substace is take to relieve or avoid withdrawal symptoms. The substace is ofte take i larger amouts or over a loger period tha was iteded. There is a persistet desire or usuccessful efforts to cut dow or cotrol substace use (icludig prior periods of abstiece). A great deal of time is spet i activities ecessary to obtai the substace, use the substace or recover from its effects. Importat social, occupatioal or recreatioal activities are give up or reduced because of substace use. The substace use is cotiued despite kowledge of havig a persistet or recurret physical or psychological problem that is likely to have bee caused or exacerbated by the substace. 5. Is there a family history of alcoholism/drug addictio i the petitioer s immediate family? YES NO If yes, idicate the family member s relatioship to the petitioer, frequecy of cotact with the petitioer, ad whether he/she is still usig ay substace. 6. Is there a history of ay alcohol or other drug-related treatmet? YES NO If yes, provide the ames ad locatios of the treatmet programs ad the dates such treatmet occurred. The petitioer must documet his/her most recet treatmet. The petitioer must submit a Treatmet Verificatio Form ad Treatmet Discharge Summary completed by the the treatmet program that provided treatmet. 7. Is there a idicatio of ay curret sigificat physical, emotioal/metal health or psychiatric disorders? YES NO If yes, the petitioer must submit a separate documet from the attedig physicia, psychiatrist or couselor which reports the diagosis, curret status ad a progosis. If metal health treatmet was completed i the last five years, a comprehesive discharge summary must be submitted from the most recet treatmet program that provided the treatmet. The petitioer will be iformed whether a Medical Report Form is required. 3

8. Is the petitioer takig ay medicatio (prescriptio or over-the-couter) that whe take aloe or i combiatio with alcohol or other drugs might impair drivig ability? YES NO If yes, idetify the medicatio ad discuss ay potetial impairmet. The petitioer will be iformed whether a Medical Report Form is required. DRIVING HISTORY: 1. How may DUI arrests does the petitioer ackowledge? Report all alcohol/drug-related drivig arrests (DUI, Illegal Trasportatio of Alcohol, Fleeig ad/or Attemptig to Elude a Police Officer, Leavig the Scee of a Property Damage, Persoal Ijury ad/or Fatal Motor Vehicle Crash, Drivig Without a Valid Licese or Permit, Drivig While Suspeded/Revoked, Auto Theft, Reckless Homicide, Reckless Drivig, etc. i ay state). Iclude a descriptio of the offese; date of arrest; state where it occurred; dispositio of the offese; ay breath, blood ad urie test results; ad whether the petitioer is curretly o probatio or parole for ay of the offeses. 2. Discuss i detail the most recet DUI arrest. This should iclude, at a miimum, the followig: a. Time ad day of arrest: b. Reaso stopped: c. Type ad amout of alcohol cosumed over what period of time: d. Petitioer s perceptio of the effect of the alcohol ad/or drugs cosumed: Does the petitioer believe that he/she was uder the ifluece at the time of the arrest? YES NO e. List ay chemical test results, icludig breath, blood (distiguish whether serum-based or whole-blood) ad urie: f. Time of first drik: Time of last drik: Time breath or chemical test give: Total cosumptio metabolism time (from the first drik util test give): g. Does the blood-alcohol cocetratio (BAC) readig correlate with the amout of alcohol cosumed, total cosumptio metabolism time ad the petitioer s body weight at that time? YES NO Explai: h. Type of substace used (other tha alcohol): Amout of substace used: Time period substace was used: Last time substace was used before alcohol/drug-related arrest: 4

All other alcohol/drug-related arrests, i ay state, icludig feloies, misdemeaors, petty offeses, ad local ordiaces: 1. How may alcohol- ad/or drug-related crimial arrests, ot previously discussed, does the petitioer ackowledge? Report all such arrests, icludig a descriptio of offese; date of arrest; state where occurred; dispositio of the offese; ad whether the petitioer is curretly o probatio or parole for ay of the offeses. 2. Discuss the last alcohol/drug-related o-dui arrest, icludig the circumstaces before, durig ad after the arrest. CORROBORATION: This sectio must iclude iformatio from the followig sources: A. Iterview with a Sigificat Other May be a family member, fried, employer, paret/guardia, etc. The summary should iclude, but ot be limited to, the followig iformatio: sigificat other s ame, age ad relatioship to the petitioer; how log he/she has kow the petitioer; how ofte he/she sees the petitioer, how log he/she has maitaied his/her preset level of cotact with the petitioer; his/her perceptio of the petitioer s curret alcohol or other drug use patter ad/or abstiece; ad whether he/she ca verify the duratio of the petitioer s curret alcohol or other drug use ad/or abstiece. This iterview requiremet caot be waived ad must be coducted i every alcohol/drug evaluatio completed. B. Objective Test Ay geerally recogized testig istrumet may be utilized if the test s reliability ad validity has bee demostrated by meas of accepted statistical methods ad procedures. Idetify the objective test admiistered ad provide a summary iterpretatio of the results of the test. Discuss how corroborative iformatio from both the iterview ad the objective test either correlates or does ot correlate with the iformatio obtaied from the petitioer. 5

CLASSIFICATION: This classificatio is based o the petitioer s alcohol/drug-related drivig arrests, crimial arrests ad symptoms of alcohol/drug abuse/depedecy. (Refer to Classificatio Defiitios o page 10 before completig this sectio.) 1. Idicate the classificatio for this DUI offeder: No-Problematic Use Problematic Use Alcoholism/Chemical Depedecy Active (Usig) Alcoholic/Chemically Depedet Oly I Remissio (Recoverig) Alcoholic/Chemically Depedet Oly NOTE: Oce it has bee determied that a petitioer is depedet o alcohol ad/or other drugs, the petitioer must be classified as Alcoholic/Chemically Depedet, regardless of whether the petitioer s depedecy is active or i remissio whe the evaluatio is coducted. 2. Provide a clear ad complete ratioale for selectig this classificatio, icludig a explaatio if the classificatio appears to coflict with those symptoms or geeral idicators you have idetified ad described i this report. PRIOR DENIAL OF DRIVING RELIEF: Complete items a, b, c, ad d oly if the petitioer has bee deied drivig relief from a previous applicatio. The evaluator/treatmet provider s respose may be completed o agecy letterhead ad attached. a. The petitioer must submit to the evaluator/treatmet provider his/her (a) last Order/Letter of Deial; (b) ad/or Letter of Rejectio of Explaatio from the BAIID Departmet reguardig a BAC violatio icurred while drivig o a RDP or MDDP; (c) ad/or Order/Letter issuig a Restricted Drivig Permit but cotaiig uresolved issues to be addressed prior to reistatemet. The evaluator/treatmet provider must effectively address the sigificat issues raised theri. Was this documetatio submitted? YES NO Petitioer s failure to provide this iformatio may result i the deial of the applicatio for drivig relief. b. Summarize how each sigificat issue was effectively addressed ad/or resolved. 6

c. Provide a clear ad complete explaatio of why this additioal iformatio either chages or does ot chage the petitioer s classificatio ad/or alters your cliical impressio. d. Provide a clear ad complete explaatio as to whether this additioal iformatio warrats or does ot warrat additioal treatmet hours. Additioal treatmet hours must be completed ad properly documeted before applyig for reistatemet of drivig privileges. RECOMMENDATIONS: Oe of the followig recommedatios must be made i accordace with the specific classificatio idicated i the previous sectio ad the requiremets for classificatios o page 9. Remedial Alcohol/Drug Educatio (No-Problematic Use) Remedial Alcohol/Drug Educatio caot be waived. The agecy providig the educatioal program must complete all sectios of the Remedial Educatio Verificatio form. Remedial Alcohol/Drug Educatio ad Alcohol/Drug Abuse Treatmet (Problematic Use) Remedial Alcohol/Drug Educatio caot be waived. Uder Illiois regulatios, treatmet recommedatios for this classificatio geerally cosists of a miimum 12-20 hours of outpatiet treatmet (group or idividual), depedig o the severity of the problem(s) idetified. The Treatmet Verificatio form must be completed ad a Comprehesive Discharge Summary must be submitted. Alcohol/Drug Depedecy Treatmet (Alcoholism/Chemical Depedecy) Uder Illiois regulatios, treatmet recommedatios for this classificatio geerally cosists of either a miimum 75 hours of itesive outpatiet treatmet or completio of a residetial/ipatiet treatmet program. The Treatmet Verificatio form must be completed ad a Comprehesive Discharge Summary must be submitted. Provide a explaatio below of ay additioal recommedatios that have bee made or if the miimum suggested treatmet recommedatios for Problematic Use ad Alcoholism/Chemical Depedecy, as state above, are cosidered iappropriate for this petitioer. If d was completed uder PRIOR DENIAL OF DRIVING RELIEF, o respose is ecessary. 7

EVALUATOR VERIFICATION (required): I certify that I have accurately reported the data collected ad required i order to complete the evaluatio. Provider s Name: (type or prit) Provider s Sigature: Date: Provider s Title: Telephoe Number: Program Name: Accreditatio/Licese Number: Address: (Street/City/State/ZIP) This evaluatio must be siged, dated ad o more tha six moths old whe received by the Secretary of State s office. PETITIONER VERIFICATION: Must be verified i the presece of the evaluator/treatmet provider. The iformatio I have provided for this Alcohol/Drug Evaluatio Uiform Report is true ad correct. I have read the iformatio cotaied i this report ad all the recommedatios have bee explaied to me. Petitioer s Name: Date: 8

CLASSIFICATION DEFINITIONS No-Problematic Use A geeral idicatio of this classificatio icludes o symptoms of substace abuse or depedece.this would iclude o patters of impairmet i family, marital, social, emotioal, occupatioal or physical fuctioig as a cosequece of alcohol or other drug use. No additioal symptoms such as chage i tolerace, blackouts or loss of cotrol. Geerally, but ot always, someoe who has oly oe DUI arrest. Blood-alcohol cocetratio (BAC) at the time of arrest is less tha.15. Problematic Use A geeral idicatio of this classificatio icludes a patter of substace abuse that has the potetial for creatig serious life problems. More tha oe arrest for DUI, especially if the arrests have occurred withi the past 10 years. A BAC at the time of arrest of.15 or greater. A idividual classified as Problematic Use may be cosidered at risk to develop a substace depedecy. Alcoholism/Chemical Depedecy This classificatio is characterized by past or preset symptoms of substace depedecy, such as a preoccupatio with alcohol or other drugs; impairmet i more tha oe of the followig areas as a direct result of loss of cotrol over cosumptio: family, marital, social, emotioal, occupatioal, physical; periodic or chroic itoxicatio; tedecy to icrease dosage; tedecy toward relapse; psychological depedece (e.g., problems with relatioships or belief that activities caot be doe as well without the substace), sleeplessess, ight sweats ad, i some cases, a physical depedece (e.g., tremors, cravigs, seizures or withdrawal symptoms) o the effects of alcohol ad/or other drugs. Ayoe who has met this defiitio at ay time i his/her life ad is curretly maitaiig abstiece remais i this classificatio ad may be cosidered i remissio. This perso should ot be classified as No-Problematic or Problematic Use. EDUCATION AND TREATMENT REQUIREMENTS FOR CLASSIFICATIONS No-Problematic Use The petitioer must complete alcohol/drug remedial educatio. Remedial Educatio caot be waived. The agecy providig the educatioal program must complete all sectios of the Remedial Educatio Verificatio form. Completio must occur after the petitioer s most recet DUI arrest ad may iclude ay other recommedatios made by the evaluator/treatmet provider. Problematic Use The petitioer must complete alcohol/drug remedial educatio ad treatmet. Remedial Educatio caot be waived. The agecy providig the educatioal program must complete all sectios of the Remedial Educatio Verificatio form. Completio must occur after the petitioer s most recet DUI arrest. Treatmet for this classificatio geerally cosists of a miimum 12-20 hours of outpatiet treatmet (group or idividual or ay combiatio of group ad idividual couselig), based o the severity of the problems idetified ad resolutio of those problems, ad may iclude ay other recommedatios made by the evaluator/treatmet provider.the Treatmet Verificatio form ad a Comprehesive Discharge Summary must be submitted. Alcoholism/Chemical Depedecy Treatmet for this classificatio geerally cosists of either 75 hours of outpatiet or itesive outpatiet couselig or residetial/ ipatiet treatmet, ad may iclude ay other recommedatios made by the evaluator/treatmet provider. The Treatmet Verificatio form ad a Comprehesive Discharge Summary must be submitted. If treatmet for Problematic Use ad/or Alcoholism/Chemical Depedecy was completed i Illiois, documetatio must also iclude copies of the treatmet pla, discharge summary ad cotiuig care pla. OTHER REQUIRED DOCUMENTATION FOR PETITIONERS CLASSIFIED AS ALCOHOLIC/CHEMICALLY DEPENDENT A. Submit three letters usig the eclosed Documetatio of Self-Help Support/Recovery Program forms to verify that you are ivolved i a self-help support recovery program such as Alcoholics Aoymous or Narcotics Aoymous. If you have a sposor oe of the letters should be writte by your sposor. B. If you are ot ivolved i a support program such as Alcoholics Aoymous or Narcotics Aoymous, you must submit three letters usig the eclosed Documetatio of No-Traditioal Support/Recovery Program forms to verify that you are utilizig a program of that ature. I additio, you must submit a letter writte by you describig the support program ad how it eables you to remai abstiet from alcohol/drugs. You should specifically idetify those idividuals who are part of your support/recovery program ad discuss how they help you remai alcohol ad drug free. NOTE: Regardless of your classificatio, you must comply with all recommedatios made by your evaluator ad/or treatmet provider. 9