Adopted: January 1995
Revised: June 2015
1. This form is to be completed by an employee’s supervisor when an incident occurs which provides reasonable suspicion that the employee is under the influence of a prohibited drug or alcohol.
______ Name of employee ___________________________________________________
______ Name of supervisor _________________________________________________
______ Name(s) of other witness(es) _________________________________________
______ Date, time and location of incident __________________________________
1.1 The supervisor should note all pertinent behavior and physical signs or symptoms which lead him or her to believe the employee has recently used or is under the influence of a prohibited substance.
1.2 The supervisor is to mark each applicable item on the following lists, and note any additional related information.
1.2.1 Nature of Incident/Cause for Suspicion
□ 1. Observed/reported possession or use of a prohibited substance
□ 2. Apparent drug or alcohol intoxication
□ 3. Observed abnormal or erratic behavior
□ 4. Arrest or conviction for drug-related offense
□ 5. Evidence of tampering on a previous drug test
□ 6. Other (e.g., flagrant violation of safety regulations, serious
misconduct, fighting or argumentative/abusive language, refusal
of supervisor instruction, unauthorized absence on the job) --
please specify: __________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
1.2.2 Unusual Behavior
□ 1. Verbal abusiveness
□ 2. Physical abusiveness
□ 3. Extreme aggressiveness or agitation
□ 4. Withdrawal, depression, mood changes or unresponsiveness
□ 5. Inappropriate verbal response to questioning or instructions
□ 6. Other erratic or inappropriate behavior (e.g., hallucinations,
disorientation, excessive euphoria, confusion) -
please specify: __________________________________
1.2.3 Physical Signs or Symptoms
□ 1. Possessing, dispensing or using a controlled substance
□ 2. Slurred or incoherent speech
□ 3. Unsteady gait or other loss of physical control; poor coordination
□ 4. Dilated or constricted pupils or unusual eye movement
□ 5. Bloodshot or watery eyes
□ 6. Extreme fatigue or sleeping on the job
□ 7. Excessive sweating or clamminess to the skin
□ 8. Flushed or very pale face
□ 9. Highly excited or nervous
□ 10. Nausea or vomiting
□ 11. Odor of alcohol
□ 12. Odor of marijuana
□ 13. Dry mouth (frequent swallowing/lip wetting)
□ 14. Dizziness or fainting
□ 15. Shaking hands or body tremors/twitching
□ 16. Irregular or difficult breathing
□ 17. Runny sores or sores around nostrils
□ 18. Inappropriate wearing of sunglasses
□ 19. Puncture marks or “tracks” on skin
□ 20. Other -- please specify: _________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
1.2.4 Written Summary -- In the space below, the supervisor should summarize the facts and circumstances of the incident, the employee’s response, the supervisor’s actions and any other pertinent information not previously noted. Include the date, times and location of reasonable suspicion testing or note if employee refused test. Attach additional sheets of paper as needed.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. If after completing this checklist you believe the employee may be under the influence, proceed as follows:
2.1 Ask the employee to meet with you at a private location. If he or she refuses, go to step 2.8.
2.2 Select an authorized witness (another supervisor) to attend the meeting with you. At the employee’s request, a representative of the employee’s union, if available, may also observe the meeting.
2.3 BEFORE asking the employee the following questions, explain the following points to the employee:
2.3.1 Any answers he or she may give to the following questions will be used to help decide whether he or she will be asked to submit to a test for the presence of drugs and/or alcohol in his or her body;
2.3.2 The answers to the following questions are private data and will only be disclosed to appropriate medical and district personnel, and the answers will not be disclosed to any other person or agency without the employee’s further authorization, and
2.3.3 He or she is not legally required to answer the following questions.
2.4 Ask the employee to read and sign the following statement:
I, voluntarily consent to answer the following questions. I acknowledge that: I have been given a copy of Independent School District 196 Policy 406, Section 3, Chemical-Free Workplace; I have been informed of the purpose and intended use of the answers to the following questions; I may refuse to answer the following questions; if I refuse to answer the following questions, I may be subject to discipline for insubordination; and the answers to the following questions will be disclosed to appropriate medical and district personnel.
Employee Witness
Date Date
--------------------------------------------------------------------------------------------------
2.5 Ask the employee the following questions, and mark the answers on this form.
a. Do you feel ill? Yes____ No____
If yes, what are the symptoms? ___________________________
b. Are you under a medical practitioner’s care? Yes ____ No ____
If yes, what is the medical practitioner’s name and address? ____________________________________________________________
____________________________________________________________
Procedure 406.3.4.2.3P
Page 4
c. Can you explain the observed behavior? ____________________________________________________________
2.6 If the explanation leads you to believe there is reasonable cause for an alcohol and/or drug test, the employee should be asked to go with an authorized district representative (a supervisor or designee) to the testing site, if in district, or other U.S. Department of Transportation-licensed laboratory or clinic if out of district.
2.7 If the employee agrees to the test:
a. The authorized district representative (a supervisor or designee) will escort the employee to the testing site or other U.S. Department of Transportation-licensed laboratory or clinic.
b. The employee should be taken or sent home. If he or she insists on driving, tell him or her the local police will be notified.
2.8 If the employee refuses the test or walks out before questioning, take the following actions:
a. Inform him or her that the refusal is considered insubordination and that he or she could be subject to dismissal. Then ask the employee again to take the test (or to meet with you).
b. If he or she again refuses, the employee should immediately be escorted from the district property, taken home or sent home.
District 196 Supervisor's Name (print) Witness Name (print)
District 196 Supervisor's Signature Witness Signature
Date Date
3. It is critical that all information concerning this incident be kept confidential.
Distribution: Original - Coordinator of Human Resources
Copy - Apple Valley Medical Clinic or other testing clinic, hospital or laboratory