Safety Program
Section 15A
Drug/Alcohol Observed Behavior
Cause Record Form
File: Document1
Revision Date: 07/13/2016
Revision #: 8
Document Owner: Safety Director
Page 1 of 2
Name of employee:
Supervisor/Foreman Name:
Other Witnesses if any:
REASON FOR OBSERVED BEHAVIOR (REASONABLE CAUSE)
Actual use
Abnormal behavior
Possession of alcohol
□
□
□
Odor detection
Possession of drugs
Other:
□
□
□
EXPLAIN DETAILS
Signature of Supervisor/Foreman:
Revision
1
2
4
5
Date
12/12/2004
12/3/2006
6/6/2006
9/6/2007
This Copy Printed: 7/28/2017
Revision / Review History
Authorized By
Changes
Safety Director
Annual review
Safety Director
Annual review
Safety Director
Changes
Safety Director
Annual review
Copyright © Wagner-Meinert LLC
Page 1 of 2
Safety Program
Section 15A
Drug/Alcohol Observed Behavior
Cause Record Form
Revision
6
7
8
9
10
11
12
13
14
Date
11/14/2007
11/14/2009
7/13/2016
This Copy Printed: 7/28/2017
File: Document1
Revision Date: 07/13/2016
Revision #: 8
Document Owner: Safety Director
Page 2 of 2
Revision / Review History
Authorized By
Changes
Safety Director
Changes
Safety Director
Annual review
Safety Director
Annual review
Copyright © Wagner-Meinert LLC
Page 2 of 2