REASONABLE SUSPICION DOCUMENTATION
FOR SIGNS OF DRUG/ALCOHOL ABUSE
Use this form every time an employee is suspected of drug or alcohol abuse by observations
of articulable actions, appearance or conduct which constitutes a major change in
appearance and/or behavior.
Employee’s Name: Department:
Date of Observation: Location:
Time of Observation: From a.m./p.m. To a.m./p.m.
OBSERVED EMPLOYEE BEHAVIOR – CHECK ALL APPROPRIATE ITEMS.
PHYSICAL BEHAVIORAL
Appearance:
Flushed complexion Change in speech pattern
Disheveled clothing Loud/Incoherent speech
Unkempt personal grooming Excessively talkative
Blood shot eyes Inappropriate laughter
Drowsiness Exaggerated pronunciation
Relaxed posture Moody/Sullen/Depressed
Eye-hand coordination problems Easily distracted
Fumbling/Poor dexterity Mood swings
Trembling extremities Loss of inhibitions/Risk taking
Physical Symptoms: Paranoid reactions to events
Spasmodic jerks Complaints of stomach “flu”
Glazed look/Inability to focus General malaise
Light sensitivity Frequent use of:
Perspiring Breath mints/Breath sprays/
Body/Breath odor of alcohol Mouth wash/Eye drops.
How is employee’s behavior different than previous observed on-the-job behavior?
To the best of my knowledge and belief, this report represents the appearance/conduct of
the above named employee, observed by me and upon which I base my decision to require
said employee to submit to reasonable suspicion drug/alcohol testing.
Signature of supervisor Signature of confirming supervisor
Date: Date:
PE135
