Reasonable Suspicion Checklist

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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:

Movements:

Eyes:

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Cooperative Calm Talkative/rapid speech Polite Sarcastic Sleepy Crying Sleeping on the job Argumentative Excited Withdrawn Mood swings Overreacts to minor things Excessive laughter Forgetful Other (describe)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