DEFERRED DEPOSIT - CIA



Reasonable Suspicion & Fitness for Duty Behavioral Observation Checklist (DOT and Non-DOT)(to be completed by PG&E Supervisor)Employee’s Name:Personnel Number:Job Classification:DOT-Covered:Yes FORMCHECKBOX No FORMCHECKBOX Work/Cell Phone:Open Workers’ Comp Claim:Yes FORMCHECKBOX No FORMCHECKBOX It is the supervisor’s responsibility to make an assessment of each employee’s fitness-for-duty. Such a determination results from the supervisor’s knowledge of the job and objective observations of an employee’s ability to perform job duties in a safe and efficient manner. Please indicate below your observations of the employee: (New =new behavior, no prior concerns) General FunctioningYESNONEWhas unreliable attendance FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has difficulty or is unable to perform normal job tasks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX is frequently absent and/or late to work FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has difficulty getting along with others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX cannot be relied upon when working alone FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has low energy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX seems unaware of hazards, does not take proper precautions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX lacks interest in work or quality of work FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Physical FunctioningYESNONEWshows unusual drowsiness and/or sleepiness FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX is unsteady when walking or sways while standing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX is slumped over or appears overly hyperactive while sitting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has difficulty bending, twisting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX finds it difficult to climb stairs, ladders, poles FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX is favoring an arm, leg, hand FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has difficulty lifting, moving boxes/equipment FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX shows a lack of manual dexterity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX demonstrates slowed responses, delayed reaction time, slowed motor activity FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX appears to have difficulty breathing, sometimes short of breath FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Possible Alcohol/Drug Use or AbuseYESNONEWbreath or clothing have an odor of alcohol and/or drugs FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX late returning from breaks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX does not respond to environmental cues FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX inwardly focused, avoiding contact with others FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX unkempt appearance, disheveled FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Emotional FunctioningYESNONEWseems depressed or has reported feelings of hopelessness, despair FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has mood swings FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX appears visibly agitated FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX seems lethargic, lacks interest in job, coworkers FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX is often anxious, nervous FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX appears suspicious or paranoid or demonstrates bizarre ideas FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX is irritable, quick to anger, argumentative FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has mentioned family problems, difficulties with spouse, concerns about health FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Cognitive Functioning: The employee has difficulty:YESNONEWunderstanding and following instructions FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX maintaining appropriate work pace FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX doing simple tasks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX completing simple tasks but needs guidance for more detailed work (whichis a change from previous work performance) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX performing repetitive tasks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX remembering instructions, seems forgetful FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX concentrating, focusing on tasks FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Vision, Speech, HearingYESNONEWcovers or hides eyes (e.g., sunglasses, low visor cap) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX seems to have difficulty with vision FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX pupils are constricted or dilated FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX eyes are extremely red or red-rimmed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX speech is slurred FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX speech is unusually rapid or exceptionally slow FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX speech garbled, not making sense FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX observed or has mentioned problems with hearing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX instructions must be repeated several times FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX does not respond unless looking directly at the person speaking FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Aggressive and/or Threatening Behavior:YESNONEWbecomes easily angry with others, escalates differences of opinion FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has demonstrated aggressive behavior (e.g., throwing things, yelling at coworkers) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has made a direct or indirect threat to hurt or kill someone FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX has intimidated others either physically or verbally (e.g., harassing phone calls or comments, stalking) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Work Performance/Attendance Issues: ___________________________________Have any of the above issues been addressed with the employee? YES FORMCHECKBOX NO FORMCHECKBOX How long have the issues been present? ___________________________________Have any job modifications or accommodations been requested or provided? If so, please describe: Describe the event(s) and or incident(s) leading up to the reasonable suspicion or FFD consultation/evaluation, including any observed behaviors not noted above: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________If appropriate, provide more description on “YES” Answers and/or other unusual behaviorsSupervisor: FORMTEXT ????? FORMTEXT ?????Date: FORMTEXT ?????(print name)(signature)Job Title: FORMTEXT ?????Office Phone: FORMTEXT ?????Cell: FORMTEXT ?????If drugs and/or alcohol-related, Second Supervisor (must be observed and documented independently)Supervisor: FORMTEXT ????? FORMTEXT ?????Date: FORMTEXT ?????(print name)(signature)Job Title: FORMTEXT ?????Office Phone: FORMTEXT ?????Cell: FORMTEXT ?????* FOR Gas- Covered employee, drug only ................
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