Reasonable Suspicion Checklist
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) ______________________________________________________________________________________________________________