403.7E6 - Drug and Alcohol Reasonable Suspicion Observation

Employee's Name                                           Date of Observation

 

Time of Observation: From _ a.m. / p.m. to _ a.m. / p.m.

 

Location:

 

Observed personal behavior: (check all appropriate items)

Speech:                                   _Normal          _Incoherent             _Confused

_Slurred          _Whispering   _Silent

 

Balance:                                  _Normal          _Swaying             _Staggering     _Falling

 

Walking and Turning:            _Normal          _Stumbling     _Swaying             _Falling          

_Arms raised for balance            _Reaching for support

 

Awareness:                             _Normal          _Confused       _Paranoid

                                                _Sleepy or Stupor       _Lack of coordination

 

Odor:                                       _Normal          _Alcohol         _Burned rope

 

Other observed behavior/odor:

 

Reasonable suspicion of current use or impaired by:             _alcohol             _ drugs.

 

Above behavior witnessed by:

Signed                                                             Date

 

Signed (optional)                                            Date

 

This form must be completed by each trained employee observing the driver suspected of drug use and/or alcohol misuse by behavior, speech and/or odor while on duty, the earlier of within 24 hours or the determination of reasonable suspicion or prior to receiving the test results. The observations must be specific, contemporaneous and articulate concerning the appearance, behavior, speech and body odor of the driver.