Fillable Reasonable Suspicion Testing Checklist Plus Consent Form (Idaho State University)

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Reasonable Suspicion Testing Checklist Plus Consent Form (Idaho State University)

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Submit Completed Form to hr@isu.edu, fax to 208-282-4976, or hand deliver to HR Office, Administration Building Room 312.
Reasonable Suspicion Testing Checklist
This checklist is used to determine and document reasonable suspicion of a potential violation of the Drug and Alcohol Free Workplace policy. In
such instances, the supervisor or manager observing the behavior with another supervisor/administrator as witness, must complete this form. The
checklist must be reviewed with HR who will consult with General Counsel, and Public Safety. Upon establishment of reasonable suspicion of on the
job impairment, HR will inform management of authorization to complete a drug and alcohol test in accordance with ISUPP 3180.
Observed Employee Name: ________________________________________ Date: __________________ Time: _______________________
Supervisor/Manager Name: ________________________________________ Title: ________________________________________________
Witness Name: __________________________________________________ Title: ________________________________________________
Physical Indicators Observed (check all that apply):
WALKING
[ ] Appears Normal
[ ] Holding On For Support
[ ] Stumbling
[ ] Unable to Walk
[ ] Unsteady
[ ] Staggering
[ ] Swaying
[ ] Falling
[ ] Other______________
FACE
[ ] Appears Normal
[ ] Red/Flushed
[ ] Pale
[ ] Sweaty
[ ] Slobbering
[ ] Grinding Teeth
[ ] Dry Mouth
[ ] Runny Nose
[ ] Other___________________
SPEECH
[ ] Appears Normal
[ ] Whispering
[ ] Slurred
[ ] Shouting
[ ] Incoherent
[ ] Silent
[ ] Rambling
[ ] Slow
[ ] Other______________
BREATH/ODOR
[ ] No Odor
[ ] Faint Alcohol Odor
[ ] Strong Alcohol Odor
[ ] Tobacco Odor
[ ] Chemical Odor
[ ] Marijuana Odor
[ ] Breath Spray/Mouthwash/Mints
[ ] Unidentifiable Odor
[ ] Other______________
STANDING
[ ] Appears Normal
[ ] Swaying
[ ] Feet Wide Apart
[ ] Rigid
[ ] Staggering
[ ] Sagging at Knees
[ ] Other______________
EYES
[ ] Appear Normal
[ ] Watery
[ ] Bloodshot
[ ] Glassy
[ ] Dilated
[ ] Closed
[ ] Droopy Eyelids
[ ] Other______________
MOVEMENT
[ ] Appears Normal
[ ] Clumsy
[ ] Fumbling
[ ] Jerky
[ ] Nervous
[ ] Slow
[ ] Hyperactive
[ ] Other______________
Appearance
[ ] Appears Normal
[ ] Messy
[ ] Dirty/Stained Clothing
[ ] Burns on Person/Clothing
[ ] Ripped/Torn Clothing
[ ] Partially Undressed
[ ] Puncture Marks/Needle Tracks
[ ] Other______________
Behavioral Indicators (check all that apply):
DEMEANOR
[ ] Cooperative [ ] Polite [ ] Calm
[ ] Talkative [ ] Silent [ ] Sleepy/Drowsy
[ ] Sarcastic [ ] Belligerent [ ] Tearful/Crying
[ ] Anxious [ ] Excited [ ] Frequent Mood Changes
[ ] Disoriented [ ] Inattentive [ ] Other ____________________________
[ ] Unconscious/unresponsive (call 911 and notify Public Safety)
ACTIONS
[ ] Normal [ ] Profane Language
[ ] Fighting/Combative [ ] Hostile
[ ] Threatening [ ] Hyperactive
[ ] Non-Communicative [ ] Sleeping on the Job
[ ] Argumentative [ ] Other__________________________________
Comments and other observations:
Additional Facts:
[ ] Presence of alcohol and/or drugs in individual’s possession or vicinity.
[ ] On the job misconduct by individual (describe) _______________________________________________________________________________
[ ] Individual admitted to being under the influence of drugs and/or alcohol on the job when observed.
[ ] Individual admitted to using drugs and/or alcohol on the job when observed.
[ ] Individual Provided Explanation for Behavior:
Is individual at least 18 years of age? [ ] Yes [ ] No If “no”, name of parent/guardian__________________________________________________
Manager and Witness sign below, certifying that the above is true and accurate to the best of their knowledge and observations:
Supervisor/Manager Signature: _________________________________________ Date: _______________ Time: __________________
Witness Signature: ___________________________________________________ Date: _______________ Time: __________________
Submit Completed Form to hr@isu.edu, fax to 208-282-4976, or hand deliver to HR Office, Administration Building Room 312.
HR USE ONLY: Review w/ General Counsel & Public Safety: _________________________ Test Authorized: Y/N_____________________
STOP: Management should NOT complete this form with the employee until authorized to do so by HR.
REASONABLE SUSPICION TESTING CONSENT FORM
Once HR, General Counsel, and Public Safety have determined reasonable suspicion exists that an employee may be impaired in the workplace, HR
will request that management present this testing consent form to the employee under suspicion.
I, ________________________________________ (individual name) as an employee of Idaho State University, have been informed that:
• HR, General Counsel, and Public Safety have concurred with management that reasonable suspicion exists that I am in violation of the
Drug and Alcohol Free Workplace Policy, ISUPP 3180 after reviewing the attached Reasonable Suspicion Checklist.
• I will be transported by my supervisor/manager and a witness to and from the designated testing location.
• The test results will be provided to an independent Medical Review Officer with Central Drug Systems, Inc.
• A positive test could result in disciplinary action up to and including termination of employment.
• I may refuse my consent to submit to the drug/alcohol test.
• I will be subject to disciplinary action up to and including termination of employment if I refuse the screening or test, adulterate or dilute
the specimen, substitute the specimen, send an imposter, or refuse to cooperate in the testing process in such a way that prevents
completion of the test.
Individual’s statement regarding the allegation of being in violation of the Drug and Alcohol Free Workplace Policy:
At the conclusion of this process, I will be instructed to make arrangements for my safe transportation home and that my supervisor may notify law
enforcement if I attempt to operate a vehicle.
I have read the form and AGREE to undergo testing for drugs and/or alcohol _______________________________ _______________________
Employee Signature Date
I have read the form and REFUSE to undergo testing for drugs and/or alcohol ______________________________ _______________________
Employee Signature Date
Witnessed by (signature): __________________________________________ Date: _________________________________________
Printed Name: ___________________________________________________ Title: _________________________________________
Testing Locations:
Pocatello
Meridian
Twin Falls
Portneuf Workmed Medical
Center
500 S. 11
th
Ave. #500
Pocatello, ID 83201
Phone: 208-239-1940
After Hours: 208-239-1800
2235 E. 25
th
Street Suite 150
Idaho Falls, ID 83404
Phone: 208-528-9000
After Hours: 208-528-9000
St. Luke’s Occupational Health
Service
520 S. Eagle Road, 2213
Meridian, ID 83642
Phone: 208-706-5447
St. Luke’s Magic Valley Regional
Medical Center
775 Pole Line Road West
Twin Falls, ID 83301
Phone: 208-814-8114
HR Rep – Attach Medtox Drug Testing Form for Respective Clinc. Medtox Drug Testing Form and Consent Form should be taken to testing location.
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Reasonable Suspicion Testing Checklist Plus Consent Form (Idaho State University)

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Completed 25 July 2020

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