Appendix
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| ____ Constricted pupils ____ Dilated pupils ____ Scratching ____ Red or watering eyes ____ Involuntary eye movements ____ Sniffles ____ Excessively active ____ Nausea or vomiting ____ Flushed skin ____ Sweating ____ Yawning ____ Twitching ____ Violent behavior |
____ Drowsiness ____ Odor of alcohol ____ Nasal secretion ____ Dizziness ____ Muscular incoordination ____ Unconsciousness ____ Inability to verbalize ____ Irritable ____ Argumentative ____ Difficulty concentrating ____ Slurred speech ____ Bizarre behavior ____ Needle marks |
| ____ Possession
of paraphernalia (such as syringe, bent spoon, metal bottle
cap, medicine dropper, glassine bag, paint can, glue tube,
nitrite bulb, or aerosol can)
____ Possession of substance that appears to possibly be a drug or alcohol ____ Other ______________________________________________________ _________________________________________________________________ _________________________________________________________________ |
|
DETERMINING REASONABLE CAUSE
If you are able to document one or more of the indicators above, ask yourself these questions to establish reasonable cause:
Y N
[ ] [ ] Has some form of
impairment been shown in the employee's appearance, actions or
work performance?
[ ] [ ] Does the impairment
result from the possible use of drugs or alcohol?
[ ] [ ] Are the facts reliable?
Did you witness the situation personally, or are you sure that
the witness(es) are reliable and have provided firsthand information?
[ ] [ ] Are the facts capable
of explanation?
[ ] [ ] Are the facts capable
of documentation?
[ ] [ ] Is the impairment
current, today, now?
Do NOT proceed with reasonable
cause testing unless all of the above questions are answered
with a YES.
TAKING ACTION
____ Reasonable cause established
____ Reasonable cause NOT
established
Prepared by:
Supervisor's/Manager's Signature:__________________________________________________