Microsoft Word - Reasonable Suspicion Checklist.doc
Reasonable Suspicion ChecklistName of Observed Employee Location ____________________________________________________________ Time am ______pmDate __When there is reasonable suspicion that an employee at work is unfit for duty, the supervisor or manager observing the behavior as well as another supervisor/manager as witness, if possible, must complete the checklist below. Where “Other” is checked, please describe.Observation ChecklistWalking: Holding on Stumbling Unable to walk Unsteady Staggering Swaying Falling Other Standing: Swaying Feet wide apart Unable to stand Rigid Staggering Sagging at knees Other Speech: Whispering Slurred Shouting Incoherent Slobbering Silent Rambling Mute Slow Other Demeanor: Cooperative Calm Talkative Polite Sarcastic Sleepy Crying Sleeping on job Argumentative Excited Other Actions: Hostile Fighting Profanity Drowsy Threatening Hyperactive Erratic Calm Resisting communication Other Eyes: Bloodshot Watery Droopy Dilated Glassy Closed Other Face: Flushed Pale Sweaty Other Appearance/ Neat Unruly Messy DirtyClothing: Stains on clothing Odor Partially dressed Bodily excrement stains Other Breath: No alcoholic odor Faint alcoholic odor Alcoholic odor Sweet/pungent tobacco odor Heavy usage, breath spray Other Movements: Fumbling Jerky Nervous Slow Normal Hyperactive Other Reasonable Suspicion ChecklistEating/ Gum Candy MintsChewing: Other Miscellaneous Presence of alcohol and/or drugs in associate’s possession or vicinity On-the-job misconduct by employee Employee admission concerning alcohol use and/or drug use or possession148590037909500148590063817500 If there are witnesses to employee’s conduct, list below:1485900-24257000114300027559000114300040449500114300053403500114300066357500114300079311500Other observations: (if accident, provide details)1143000-501015001143000-371475001143000-24193500114300027559000114300040513000114300053467000114300066357500114300079311500114300092265500Employee’s explanation of reasons for their conduct:1143000-759460001143000-630555001143000-501015001143000-371475001143000-24193500Once above portion of form has been completed by you and a witness, you are now ready to take a position with the employee. Be certain to follow company procedures as outlined in our drug-free policy.(Check one) Employee has agreed to testing Employee has not agreed to testing1143000165100037731701651000Supervisor/Manager SignatureDate1143000165100037731701651000Witness SignatureDate ................
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