CITY AND COUNTY OF DENVER
OBSERVED BEHAVIOR - REASONABLE CAUSE FORM
Employee Name:
Employee ID Number:
Date of Observation:
TIME: FROM
TIME: TO
Location / Activity:
1. Presence of Drugs, Drug Odor and / or Drug
Paraphernalia (Specify)
2. Presence of Alcohol Odor and / or Alcohol Itself
or Containers (Specify)
3. Appearance:
Normal
Flushed
Puncture Marks / Tracks
Disheveled
Bloodshot Eyes
Inappropriate Wearing of Sunglasses
Dilated / Constricted Pupils
Profuse Sweating
Tremors
Dry-Mouth Symptoms
Runny Nose /Sores
Other:
4. Behavior
Speech:
Normal
Confused
Awareness:
5. Motor Skills
Balance:
Walking &
Turning:
Incoherent
Slowed
Slurred
Whispering
Silent
Other:
Normal
Confused
Lack of Coordination
Mood Swings
Euphoria
Lethargic
Paranoid
Disoriented
Other:
Normal
Falling
Normal
Stumbling
Swaying
Staggering
Other:
Swaying
Arms Raised For Balance
Falling
Reaching for Support
Other:
6. Other Observed Actions or Behavior (Specify)
Witnessed By (If Available:
Title
Date
Time:
Title
Date
Time:
Signature
Signature
This Document must be presented and signed by the witnesses within 24 hours of the observed behavior or before the results
of the test are released, whichever is earlier. (49 CFR 382.307 (F)).