DRUG AND ALCOHOL TESTING – IMPAIRMENT CHECKLIST DOCUMENTATION OF OBSERVED BEHAVIOR FOR REASONABLE SUSPICION Directions: This checklist should be used to record behavior of an employee who is at work and seemingly unfit for duty. Circle all the items that apply. A copy of the completed form should be sent to the appropriate personnel office. Employee Name: _______________________________ Employee Unique ID: _______________ Date Observed: ______________ Time Observed: _________________ Location: __________________ WALKING Stumbling Unsteady Staggering Holding On Unable to Walk Swaying STANDING Swaying Staggering Rigid Sagging Knees Unable to Stand Feet Wide Apart SPEECH Shouting Rambling Incoherent Speech Silent Mute Whispering Slurred Slow Slobbering DEMEANOR Impolite Silent Agitation Unruly Uncooperative Talkative Irritability Fearful Sleepy Excited Hostility Crying Sarcastic Argumentative ACTIONS Hostile Erratic Hyperactive Fighting Tremors Threatening Profanity Drowsiness Aggressive Behavior Resisting Communication MENTAL STATE Obsessions Disorientation Hallucinations Poor Concentration Memory Loss Delusions EYES Bloodshot Droopy Watery Closed Dilated Glassy FACE Flushed Pale Sweaty APPEARANCE/ CLOTHING Messy Dirty Neat Having Odor Jerky Slow Normal Partially Dressed MOVEMENTS Fumbling Nervous EATING/ CHEWING Gum Candy Mints Other ________ PERFORMANCE Acute Work Errors Lack of Coordination in Movement Lack of Performing Normal Tasks Work Related Accident or Injury Diminished Capacity, Inability to Perform Supervisor/Observer: _____________________ Print Name ______________________ Sign Name ____________ Date Witness/Observer: _____________________ Print Name ______________________ Sign Name ____________ Date
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