SUPERVISOR’S REPORT OF REASONABLE SUSPICION
-Confidential-
Name: Date:
Department: Title:
This form is to be completed whenever there is reasonable suspicion that an employee is under the influence
of alcohol and/or prohibited drug substance. A supervisor and a Department Director shall note all pertinent
behavior and physical signs which led them to believe that the employee is under the influence of alcohol
and/or a prohibited drug substance. The Department Director shall contact Human Resources for reasonable
suspicion testing authorization. In the event that Human Resources in unavailable, the Department Director
shall contact the City Administrator’s office. Upon authorization, the employee will be required to undergo
drug and/or alcohol testing.
Name/Title:
Name/Title:
Date of Observation: Time:
Location:
Circumstances which existed to warrant the testing for reasonable suspicion were as
follows:
Evidence that an employee has used, possessed, sold, solicited, or transferred drugs while
working, while on the employer’s premises, or while operating the employer’s vehicle,
machinery, or equipment.
Observable phenomena while at work, such as direct observation of drug use of the
physical symptoms or manifestations of being under the influence of a drug or alcohol.
Abnormal conduct or erratic behavior while at work or a significant deterioration work
performance.
Summarize the facts and circumstances of the accident or incident, employee response, supervisor actions,
and any other pertinent information not previously noted on this form. Attach additional sheets as needed.
Appendix E
Form 19
PERSONS OBSERVING BEHAVIOR (At least one Department Director required.)
