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Supervisor’s checklist for making Reasonable Suspicion determination Employee’s name Department Date(s) Reasonable suspicion of current use or impairment by □ Alcohol □ Drugs □ Both Step 1: Using the attached sheets indicate (check off) the observed signs, or behaviors Step 2: If you are able to document one or more of the indicators from the observation checklist or behavior checklist ask yourself the following questions to establish reasonable suspicion: 1. Has some form of impairment been observed in the employee’s appearance, behavior, motor skills, etc.? □ Yes □ No 2. Did you witness these impairments personally? □ Yes □ No 3. Are the facts capable of explanation and documentation? □ Yes □ No 4. Is the impairment current, now? □ Yes □ No 5. Could the impairment be caused by a possible use of drugs or alcohol? □ Yes □ No Step 3: Do NOT proceed with reasonable suspicion testing unless you answered all of the questions above with a YES. Step 4: Reasonable suspicion was established □ Yes □ No Additional comments: Your signature Corroboration by a second supervisor □ Yes □ No If yes, second Supervisor’s signature City of Laramie ---PAGE BREAK--- Observation Checklist Walking: Holding on Stumbling Unable to walk Unsteady Staggering Swaying Falling Other: Standing: Swaying Feet wide apart Unable to stand Rigid Staggering Sagging at knees Other: Speech: Whispering Slurred Shouting Incoherent Slobbering Silent Rambling Mute Slow Other: Demeanor: Cooperative Calm Talkative Polite Sarcastic Sleepy Crying Silent Sleeping on job Argumentative Excited Other Actions: Hostile Fighting Profanity Drowsy Threatening Hyperactive Erratic Calm Resisting communication Other: Eyes: Bloodshot Dilated Constricted Droopy Glassy Closed Watery Other: Face: Flushed Pale Sweaty Other: Appearance: Neat Unruly Messy Dirt Stains on cloths Having odor Partially dressed Other: Breath: No alcoholic odor Faint alcoholic odor Distinct alcoholic odor Movements: Fumbling Jerky Nervous Slow Hyperactive Other: Awareness: Lethargic Confused Nervous Slow Hyperactive Paranoid Mood swings Disoriented Euphoric Other: Miscellaneous: Presence of alcohol and/or drugs in associate’s possession or vicinity On-the-job misconduct by employee Employee admission concerning alcohol use and/or drug use or possession If there are witnesses to employee’s conduct, list below: City of Laramie ---PAGE BREAK--- Behavior Checklist Absenteeism Multiple instances of unauthorized leave. Excessive use of sick leave. Frequent Monday/Friday absences. Excessive tardiness, especially on Monday mornings or after lunch. Leaving work early. Peculiar or unbelievable excuses for absences. Frequent, unscheduled short-term absences. On-the-Job Absenteeism Continued absences from work site. Physical illness on the job. Frequent trips to the bathroom. Sleeping or dozing off on the job. High Accident Rate More Accidents on the job than the “norm.” Near accidents on the job. Accidents off the job. Failure to wear safety gear. Complaints from co-workers regarding disregard of safety standards. Difficulty Concentrating/ Confusion Work requires greater effort. Job takes more time. Trouble recalling instructions, details, etc. Increasing difficulty handling assignments. Trouble recalling his/her own mistakes. Gives conflicting information or instructions. Has trouble coordinating schedules. Inconsistent Work Patterns Alternate periods of high and low productivity. Submission of incomplete reports and data. Reporting Unfit for Work Comes to work in an obviously unfit condition Changes in Personal Habits Different behavior after lunch than before. Decreased appearance or personal hygiene. Erratic Behavior Withdrawn or improperly talkative. Argumentative. Displays violent behavior. Has exaggerated sense of self-importance. Spends excessive amount of time on the phone. Irritable. Depressed or highly emotional. Motivation Less commitment to the job. Unconcerned about quality or quantity of output. Frequently says he or she is dissatisfied. Lower Job Quality/Performance Misses deadlines. Mistakes due to inattention. Increased errors. Fails to follow procedures. Wastes material. Doesn’t take time to do the job right. Makes poor decisions. Co-workers or customers complain. Improbable excuses for poor job performance. Mismanages budget. Co-workers cover for his work responsibilities. Lower Quantity/Productivity Inconsistent work pace. Overwhelmed by realistic workload. Consistently falls behind in work. Doesn’t keep commitments. Takes longer and longer to do the same job. Reduced Job Knowledge/Skill Doesn’t know work tasks. Unable to work independently. Frequently needs instruction. Doesn’t use equipment properly. Poor Relationships on the Job Over-reaction to real or imagined criticism. Wide swings in morale and motivation. Borrowing money from co-workers. Unreasonable resentments. Unable to work with others. Uses employee time and skills inefficiently. Frequent complaints from co-workers. Avoids professional activities or training City of Laramie