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Reasonable Suspicion Checklist

LINK TO EDITABLE FORM: Click Here - Editable Employee (Internal) Reasonable Suspicion Checklist

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EXPERTISE | EXPERIENCE | INTEGRITY

Reasonable Suspicion Checklist

(The following checklist should be completed when a manger or supervisor suspects drug or alcohol use based on the physical appearance and behavior of the employee. All other managers or supervisors who witnessed the employee being unfit for duty should also complete the checklist.)

PART 1: EMPLOYEE INFORMATION

Employee Name: ________________________________________________________________________________________________________________________

Employee Job Title: ______________________________________________________________________________________________________________________

Observation Date: _______________________________________________________________________________________________________________________

Observation Time (indicate a.m. or p.m.): _______________________________________________________________________________________________

Location: _________________________________________________________________________________________________________________________________

PART 2: OBSERVATIONS

(Place a checkmark next to any of the following observations exhibited by the employee)

PHYSICAL

Walking

    Holding on Stumbling Unable to walk Unsteady Staggering Swaying Falling Other (describe) _____________________________________________________________________________________________________________

    Standing:

      Swaying Feet wide apart Unable to stand Rigid Staggering Sagging at knees Dizziness Other (describe) ______________________________________________________________________________________________________________

      Movements:

        Fumbling Jerky Nervous Slow Normal Hyperactive Reduced reaction time Not following tasks Diminished coordination Tremors Other (describe) ______________________________________________________________________________________________________________

        Eyes:

          Bloodshot Watery Droopy Glassy Closed Dilate/constricted Pupils Other (describe) ______________________________________________________________________________________________________________

          Face:

            Flushed Pale Sweaty Other (describe) ______________________________________________________________________________________________________________

            Breath:

              No alcoholic odor Faint alcoholic odor Alcoholic odor Chemical odor Sweet/pungent tobacco odor Heavy use of breath spray Other (describe) ______________________________________________________________________________________________________________

              Speech:

                Whispering Slurred Shouting Incoherent Slobbering Silent Rambling Mute Slow Other (describe) ______________________________________________________________________________________________________________

                Appearance:

                  Neat Unruly Messy Dirty Stains on clothing Marijuana odor Partially dressed Bodily excrement stains Visible puncture marks or tracks Burnt rope smell on clothes, hair, body Excessive sweating in cool area Other (describe) ______________________________________________________________________________________________________________
                  BEHAVIORAL

                  Demeanor:

                    Cooperative Calm Talkative/rapid speech Polite Sarcastic Sleepy Crying Sleeping on the job Argumentative Excited Withdrawn Mood swings Overreacts to minor things Excessive laughter Forgetful Other (describe) ______________________________________________________________________________________________________________

                    Actions:

                      Hostile Fighting Profanity Drowsy Threatening Erratic Hyperactive Calm Resisting communication Paranoid Possessing, using, or distributing an illegal substance Baseless panic Other (describe) ______________________________________________________________________________________________________________

                      Appetite:

                        Always munching on something Constantly chewing gum Frequently eating candy Popping mints often Other (describe) ______________________________________________________________________________________________________________

                        Miscellaneous:

                          On-the-job misconduct by employee ________________________________________________________________________________________ Employee admission to alcohol and/or drug use or possession _____________________________________________________________ Presence of alcohol and/or drugs in employee's possession or vicinity (cups, bags, containers, beverages, etc.)
                          No presence of alcohol and/or drugs in employee's possession or vicinity (cups, bags, containers, beverages, etc.)

                          CORROBORATING WITNESSES

                          (List of names of all witnesses to the employee's conduct below.)

                          __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

                          OTHER OBSERVATIONS

                          (List below any other observations not included in this checklist. Provide details for any accident that the employee in question caused or potentially was involved in.)

                          __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

                          PART 3: EMPLOYEE'S RESPONSE

                          (Document below the employee's explanation or reasons for their conduct.)

                          __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

                          PART 4: ACTION PLAN

                          Once parts 1-3 of this Reasonable Suspicion Checklist are completed by you and a witness, you can proceed to an action plan in a meeting with the employee. Remember to follow your company's procedures as outlined in its drug-free policy. Place a checkmark next to the applicable action as agreed upon with the employee. (Call HR prior to final decision, will issue consent form to employee)

                            Employee has agreed to testing Employee has refused testing
                                Yes No
                                  No further action at this time (reason provided) _____________________________________________________________________________
                                  Final notes regarding discussion of drug testing with employee:

                                  __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


                                  __________________________________________________________________________________________________                  _____________________________                                      Signature of supervisor filling out checklist                                                                                Date


                                  __________________________________________________________________________________________________                   ____________________________                                       Signature of 2nd supervisor witness                                                                                           Date

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