DRUG AND ALCOHOL TESTING – IMPAIRMENT CHECKLIST

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