REASONABLE SUSPICION CHECKLIST

REASONABLE SUSPICION CHECKLIST
Directions: Supervisor or Manager, please document your observations of the employee's behavior and indications on this form. You must personally observe the probable indicators of substance and/or alcohol use and note your observations below.
Employee name:
Date:

MonthDayYear
Date
Location of observations:
Time:

Hour Minutes

AM/PM Option
Name of observer:
Check All That Apply:
Speech

Slurred, thickSlowRapidSilentLoudHostileTalkativeIncoherentDifficulty speakingCursing, inappropriateNonsensical, silly
Eyes

Bloodshot/ReddenedPupils dilatedPupils constrictedRepetitive jerky motionGlazed appearanceDroopy/partially closedTearing, wateryUnfocused, blank stare
Odor

Alcohol smell on breath or clothingChemical odorBurnt rope odorOther Odor
Mood

Hostile/ AngryElated, "up"Irritable, agitatedAnxiousCombativeAggressiveViolentEvasiveSad/depressed
Mental

Poor judgmentDecreased inhibitionsDisorientedUnpredictableDistractedDrowsy/sleepyRestlessSuspicious/paranoidWithdrawn
Balance

SlowedNormalQuickenedStaggeringSwayingFallingHolding onUnsteady/uncoordinatedClumsy
Movement

SlowedNormalQuickenedShakingTremors
Appearance

FlushedSweatingCold, clammyDisheveled, messyVomit on clothing
Other

Frequent use of breath mints, gum, mouthwashPhysical evidence (like liquor bottle, drug paraphernalia)Other
I certify that I have had training in the signs & symptoms of substance use and alcohol abuse, and to the best of my judgment reasonable suspicion exists based on the physical and behavior indicators noted above.
Signed:
Date:

MonthDayYear
Date
2nd Observer, if required:
Date:

MonthDayYear
Date

REASONABLE SUSPICION CHECKLIST

Check All That Apply: