Date: __________________________
Employee name: _____________________________________________
Job title: ____________________________________________________
Location/Department: __________________________________________
Prior to sending any employee for drug or alcohol testing due to a reasonable suspicion, this form must be completed by two members of management who have had a first-hand observation or conversation with the employee. In rare situations, a second member of management may not be available to witness the behavior. If the employee is in a safety sensitive area, remove them from work immediately until a second observer can talk with the employee and/or a decision can be made on whether testing is necessary.
When completing the following document, list all observations you noticed. Be as specific as possible including names of employees/witnesses, when and where you noticed these behaviors occurring, what the employee was doing at the time and any witnesses of these events. Include any observations or changes in appearance, smell, speech, movement or actions of the employee. Some signs of impairment may include slurred speech, difficulty walking, clumsiness, dilated pupils, watery and/or red eyes.
First observer's name: ___________________________________________
Job title: ______________________________________________________
Observations: __________________________________________________
_____________________________________________________________
Signature: ______________________________ Date: __________________
Second observer's name: _________________________________________
Job title: ______________________________________________________
Observations: __________________________________________________
_____________________________________________________________
Signature: ______________________________ Date: __________________
Once the observations are documented, management should immediately meet with HR, if available, and make a decision as soon as possible on whether or not to send the employee for reasonable suspicion testing to rule out the possibility that they may be under the influence of drugs or alcohol at work. This decision should be made and handled in accordance with [Company Name]'s drug and alcohol policy and procedure.
Describe action taken: ____________________________________________________
______________________________________________________________________
______________________________________________________________________
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