Reasonable Suspicion – Southam and Associates

Employee Full Name *

First

Last

Employee Job Title: *

Observation Date and Time: *

Date

Time

Location: *

PHYSICAL OBSERVATIONS / WALKING (Place a checkmark next to any of the following observations exhibited by the employee.)

PHYSICAL OBSERVATIONS / STANDING: (Place a checkmark next to any of the following observations exhibited by the employee.)

PHYSICAL OBSERVATIONS / MOVEMENTS: (Place a checkmark next to any of the following observations exhibited by the employee.)

PHYSICAL OBSERVATIONS / EYES: (Place a checkmark next to any of the following observations exhibited by the employee.)

PHYSICAL OBSERVATIONS / FACE: (Place a checkmark next to any of the following observations exhibited by the employee.)

Flushed
Pale
Sweaty
Other

PHYSICAL OBSERVATIONS / BREATH: (Place a checkmark next to any of the following observations exhibited by the employee.)

PHYSICAL OBSERVATIONS / SPEECH: (Place a checkmark next to any of the following observations exhibited by the employee.)

PHYSICAL OBSERVATIONS / APPEARANCE: (Place a checkmark next to any of the following observations exhibited by the employee.)

BEHAVIORAL OBSERVATIONS / DEMEANOR: (Place a checkmark next to any of the following observations exhibited by the employee.)

BEHAVIORAL OBSERVATIONS / ACTIONS: (Place a checkmark next to any of the following observations exhibited by the employee.)

MISCELLANEOUS

Presence of alcohol and/or drugs in employee’s possession or vicinity
On-the-job misconduct by employee
Employee admission to alcohol and/or drug use or possession

CORROBORATING WITNESSES (List names of all witnesses to the employee's conduct below) *

Other observations | (List below any other observations not included in this checklist. Also provide details for any accident that the employee in question caused or was involved in.)

EMPLOYEE’S RESPONSE (Document below the employee’s explanation or reasons for his/her conduct)

Once the above parts of this Reasonable Suspicion Checklist are completed by you and a witness, you can proceed to an action plan in a meeting with the employee. Remember to follow your company’s procedures as outlined in its drug-free policy. Place a checkmark next to the applicable action as agreed upon with the employee: *

Employee has agreed to testing
Employee has NOT agreed to testing
Employee referred to MAP / EAP
No further action at this time

Witness Signatures will be gathered on a hard copy of this report in this section: