Code No. 4O3.10E6
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 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 tile test results. The observations must be specific, contemporaneous and articulable concerning the appearance, behavior, speech and body odor of the driver.
Revised 7-17-23