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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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