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NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

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ADDENDUM B<br />

Police Department<br />

OVI / Accident<br />

Medical Condition Form<br />

Pursuant to Section 4511.191 of the <strong>Ohio</strong> Revised Code, a person who operates a vehicle, upon the highway or<br />

property used for public vehicular travel or parking is deemed to have consented to a chemical test of his blood,<br />

breath, or urine for purposes of determining its alcohol or drug content. A person is deemed not to have<br />

withdrawn his consent if “unconscious or otherwise in a condition rendering him or her incapable of refusing<br />

such a test.”<br />

(Suspect)<br />

is currently being treated<br />

by<br />

(Medical Facility)<br />

and has been determined by<br />

(Treating Medical Personnel)<br />

to be unconscious or otherwise in a condition rendering him or her incapable of determining whether or not to<br />

submit to a chemical test of his or her blood, breath, or urine.<br />

I have requested<br />

(Treating Medical Personnel)<br />

to obtain a blood specimen to determine the idividual’s blood alcohol/ drug content.<br />

Officer<br />

Date<br />

If applicable, attach to informational statement (U-10.100)<br />

PD-99-126<br />

Revised December 10, 2010

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