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.
