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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

Standing: