OBSERVED BEHAVIOR
REASONABLE SUSPICION
RECORD
Name:
CORPORATE OFFICE USE ONLY
Employee Number
Location
Incident Number
Date Observed:
Location
From (Time)
To (Time)
Supervisor
Driver
Non-Driver
Record employee observed behavior for reasonable suspicion for the use of alcohol or controlled substances. According 49 CFR 382.307
Reasonable Suspicion Testing , the employer shall require the driver to submit to a controlled substance or alcohol test if a supervisor who
is trained in accordance with 382.603 determines that reasonable suspicion exists.
Reasonable suspicion determined for:
Alcohol
Drugs
Mark items that apply and describe specifics
1.
2.
3.
4.
WALKING/BALANCE
____Stumbling
____Swaying
____Sagging at knees
_____Staggering
_____Unsteady
_____Feet wide apart
_____Falling
_____Holding on
_____Unable to stand
_____Rigid
SPEECH
_____Shouting
_____Slurred
_____Whispering
_____Slobbering
_____Slow
_____Incoherent
_____Rambling
ACTIONS
_____Resisting communications
_____Fighting/Insubordinate
_____Hyperactive
5.
FACE
6.
Flushed
APPEARANCE/CLOTHING
Disheveled
Having Odor
8.
9.
_____Hostile
_____Unsteady
_____Indifferent
_____Drowsy
_____Erratic
EYES
Bloodshot
Droopy
7.
_____Insulting
_____Profanity
_____Crying
Watery
Closed
Dilated
Wearing Sunglasses
Pale
Sweaty
Messy
Dirty
Stains on Clothing
Partially Dressed
BREATH
Alcoholic Odor
Faint alcohol odor
MOVEMENTS
Fumbling
Jerky
Slow
EATING/CHEWING
Gum
Candy
Mints
Other Observations:
Glassy
No alcohol odor
Marijuana odor
Nervous
Tobacco
Hyperactive
Other