REASONABLE CAUSE/SUSPICION OBSERVATION REPORT
(STRICTLY CONFIDENTIAL)
EMPLOYEE:______
PERIODOF EVALUATION:______
SUPERVISOR #1,
NAME AND TELEPHONE:______
SUPERVISOR #2,
NAME AND TELEPHONE:______
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This checklist is intended to assist a supervisor in referring a person for reasonable cause/suspicion drug and/or alcohol testing. Has the employee manifested any of the following behaviors? Indicate (D) if documentation exists.
A. APPEARANCE, BEHAVIOR, SPEECH, BODY ODORS
YESNO
______1. Smell of alcohol on person
______2. Smell of marijuana on person
______3. Slurred speech
______4. Confused speech
______5. Fragmented speech
______6. Unusually slow speech
______7. Unusually fast speech
______8. Unusually soft speech
______9. Unusually loud speech
______10. Disorientation: Is employee confused about where he or she is?
______11. Disorientation: Is employee confused about what day it is?
______12. Disorientation: Is employee confused about what time it is?
______13. Apparent inability to focus on work?
______14. Unusual or unexplained resistance to authority or refusal to follow reasonable directions?
______15. Lack of motor coordination?
______16. Belligerent?
______17. Ecstatic?
______18. More nervous than usual?
______19. Giddy?
______20. Talkative?
______21. Drowsy?
______22. Pale appearance?
______23. Flushed appearance?
______24. Excessive perspiration?
______25. Excessive trips to the restroom?
______26. Bloodshot eyes?
______27. Dilated pupils?
______28. Pinpoint pupils?
______29. Traces of alcohol in containers?
______30. Confession by employee that he/she was drinking alcohol?
______31. Confession by employee that he/she was using drugs?
______32. Confirmation by other employees?
______33. Presence of substances appearing to be drugs?
______34. Presence of drug paraphernalia?
______35. Weariness, fatigue or exhaustion?
______36. Yawning excessively?
______37. Deteriorating physical appearance?
______38. Disheveled appearance?
YESNO
______39. Blank stare or expression?
______40. Sudden and/or unpredictable change in energy level?
______41. Unusually energetic?
______42. Shaking or trembling hands?
______43. Unsteady or swaying?
______44. Stumbling or staggering?
______45. Falling down?
______46. Lack of coordination?
______47. Sunglasses worn at inappropriate times?
______48. Changes in appearance after breaks or lunch?
______49. Withdrawal and avoidance of peers?
______50. Agitated?
______51. Aggressive?
______52. Breathing or swallowing difficulties?
______53. Unusual sneezing/nasal congestion?
______54. Needle marks on arms?
______55. Nausea or vomiting?
______56. Dizziness?
______57. Other erratic or inappropriate behaviors (please describe):
______
A. QUALITY AND QUANTITY OF WORK
YESNO
______1. Clear refusal to do assigned tasks
______2 Significant increase in errors
______3. Repeated errors in spite of increased guidance
______4. Decreased efficiency or productivity
______5. Inconsistent, "up and down" quantity/quality of work
______6. Behavior that disrupts workflow
______7. Careless operation of equipment
______8. Careless performance of job duties
______9. Procrastination on significant decisions or task
______10. More than usual supervision necessary
______11. Frequent, unsupported explanations for poor work performance
______12. Noticeable change in written or verbal communication
______13. Other (please specify) ______
______
B. INTERPERSONAL WORK RELATIONSHIPS
YESNO
______1. Significant change in relations with co-workers, supervisors
______2 Frequent or intense arguments
______3. Verbal abusiveness
______4. Physical abusiveness
______5. Persistently withdrawn or less involved with people
______6. Intentional avoidance of supervisor
______7. Expressions of frustration or discontent
______8. Change in frequency or nature of complaints
______9. Complaints by co-workers or subordinates
______10. Cynical, "distrustful of human nature" comments
______11. Unusual sensitivity to advice or critique of work
______12. Unpredictable response to supervision
______13. Passive-aggressive attitude or behavior, doing things "behind your back"
C. GENERAL JOB PERFORMANCE
YESNO
______1. Excessive unauthorized absences-number in last 12 months
______2. Excessive tardiness-number in last 12 months
______3. Frequent Monday/Friday absence or other pattern
______4. Frequent unexplained disappearances
______5. Excessive "extension" of breaks or lunch
______6. Frequently leaves work early-number of days per week or month
______7. Increased concern about (actual incidents) safety offenses involving the employee
______8. Experiences or causes job accidents
______9. Major change in duties or responsibilities
______10. Interferes with or ignores established procedures
______11. Inability to follow through on job performance recommendation
D. PERSONAL MATTERS
YESNO
______1. Changes in or unusual personal appearance (dress, hygiene)
______2. Changes in or unusual speech (incoherent, stuttering, loud)
______3. Changes in or unusual physical mannerisms (gesture, posture)
______4. Changes in or unusual facial expressions
______5. Changes in or unusual level of activity-much reduced/increased
______6. Changes in or unusual topics of conversation
______7. Engages in detailed discussions about death, suicide, harming others
______8. Increasingly irritable or tearful
______9. Persistently boisterous or rambunctious
______10. Unpredictable or out-of-context displays of emotion
______11. Unusual fears
______12 Lacks appropriate caution
______13. Engages in detailed discussion about obtaining/using drugs/alcohol
______14. Makes unfounded accusations toward others, e.g., has feelings of persecution
______15. Secretive or furtive
______16. Memory problems (difficulty recalling instructions, data, past behaviors)
______17. Frequent colds, flu, excessive fatigue, or other illnesses
______18. Makes unreliable or false statements
______19. Unrealistic self-appraisal or grandiose statements
______20. Temper tantrums or angry outbursts
______21. Demanding, rigid, inflexible
______22. Major change in physical health
Other information/observations - (Please be specific & attach additional sheet as needed).
______
SUPERVISOR #1 (SIGN & DATE)SUPERVISOR #2 (SIGN & DATE)