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) ______________________________________________________________________________________________________________