"Ignition Interlock Incident Report Form" - Nebraska

Ignition Interlock Incident Report Form is a legal document that was released by the Nebraska Department of Motor Vehicles - a government authority operating within Nebraska.

Form Details:

  • Released on January 1, 2014;
  • The latest edition currently provided by the Nebraska Department of Motor Vehicles;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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Download "Ignition Interlock Incident Report Form" - Nebraska

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Nebraska Department of Motor Vehicles
IGNITION INTERLOCK INCIDENT REPORT FORM
Reporting Facility Name:
Address:
City, State, Zip:
Telephone #:
Email:
Technician Completing Report:
Date:
Reporting Time
to
Report Date:
Report Sent Via: (check all that apply)
Fax
U.S. Mail
Email
Clients Name:
Date of Birth:
Driver License Number (if available):
Address:
Telephone
Client Vehicle Description:
Year __________ Make __________ Model __________ Color __________
VIN # ________________________________________________________
Test Failures (BAC results of 0.03 or above)
None recorded
Failures recorded; fail pattern, in our opinion, does not indicate consumption of beer, wine, or spirits.
Failures recorded; fail pattern, in our opinion, indicates consumption of beer, wine or spirits.
(See attached report for the following dates:
)
Tampering or Circumvention
No suspected attempts to tamper with or circumvent the IID were recorded.
Suspected attempts to tamper with or circumvent the IID were recorded.
(See attached report for the following date:
)
January 2014
Reset
Print
Nebraska Department of Motor Vehicles
IGNITION INTERLOCK INCIDENT REPORT FORM
Reporting Facility Name:
Address:
City, State, Zip:
Telephone #:
Email:
Technician Completing Report:
Date:
Reporting Time
to
Report Date:
Report Sent Via: (check all that apply)
Fax
U.S. Mail
Email
Clients Name:
Date of Birth:
Driver License Number (if available):
Address:
Telephone
Client Vehicle Description:
Year __________ Make __________ Model __________ Color __________
VIN # ________________________________________________________
Test Failures (BAC results of 0.03 or above)
None recorded
Failures recorded; fail pattern, in our opinion, does not indicate consumption of beer, wine, or spirits.
Failures recorded; fail pattern, in our opinion, indicates consumption of beer, wine or spirits.
(See attached report for the following dates:
)
Tampering or Circumvention
No suspected attempts to tamper with or circumvent the IID were recorded.
Suspected attempts to tamper with or circumvent the IID were recorded.
(See attached report for the following date:
)
January 2014
Suspected disconnections of the IID from the vehicle’s electrical system were recorded (power
disconnects):
Client credibly indicated that mechanical service was performed on the vehicle.
Client had no credible reason why the power supply to the IID was interrupted.
(See attached report for the following dates:
)
Violation Reset (Failed or “Not Taken”) Random (While Driving) Retest:
None recorded.
Failures recorded; fail pattern, in our opinion, does not indicate consumption of beer, wine or spirits.
Failures recorded; fail pattern, in our opinion, indicates consumption of beer, wine or spirits.
(See attached report for the following dates:
)
Test not taken (client ignored or perhaps disabled honking horn without attempting to take a test or
shut off the vehicle).
(See attached report for the following dates:
)
IID removed prior to expiration of client’s ignition interlock permit and period of revocation.
Additional Technician’s Comments:
If possible: please complete this report in its entirety. Report shall be faxed, emailed, and or sent via U.S.
Mail to the following:
Nebraska Department of Motor Vehicles
Motor Vehicle Fraud Unit
301 Centennial Mall South
P.O. Box 94789
Lincoln NE 68509-4789
Fax: 402-471-3190
Email:
dmv.fraudunit@nebraska.gov
January 2014
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