SOP 104.58-att-12: Behavioral/Incident Documentation Form (for Reasonable Suspicion Drug and Alcohol Testing)

Division:
Administrative & Finance
Effective Date:
August 19, 2020
Topic Area:
104 Policy-HR Appearance/Conduct/Evaluations
PowerDMS:
View on PowerDMS
Length:
150 words

Summary

This form is used to document observable behavior and physical signs that may indicate an employee is under the influence of drugs or alcohol, which would justify reasonable suspicion testing. Supervisors use this form to record detailed observations of incidents, including physical characteristics, speech patterns, balance, and behavior. The completed form is retained in the local personnel office for two years.

Key Topics

  • reasonable suspicion testing
  • drug testing
  • alcohol testing
  • behavioral documentation
  • employee conduct
  • incident report
  • observable signs of impairment
  • supervisor documentation
  • substance abuse
  • testing referral

Full Text

SOP 104.58
Attachment 12

8/19/20

Behavioral / Incident Documentation Form
(for Reasonable Suspicion Drug and Alcohol Testing)

Employee’s name: ____________________________________________________________

Name of Supervisor reporting the incident:________________________________________

Work Location: ____________________ Location of incident: ________________________

Employee’s Job Title: ____________________________ Position #: ____________________

Observation:
Date of Observation: _____________Time: __________ Length of time observed: _________

Observed by: ___________________ Witnesses: ____________________________________

Description of Incident:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Observed behavior includes: (circle applicable)

|Breath/odors:|Strong, faint, moderate, none,
other:|
|---|---|
|Eyes:|Bloodshot, Glassy, heavy eyelids, fixed or dilated pupils, normal,
other:|
|Speech:|Confused, Stuttered, thick tongued, mumbled, slurred, normal,
other:|
|Attitude:|Excited, indifferent, combative, profane, insulting, sleepy, cocky,
talkative, normal, other:|
|Balance:|Falling, swaying, wobbling, other:|
|Walking:|Falling, Swaying, staggering, stumbling,
other:|
|Turning:|Falling, Swaying, staggering, stumbling,
other:|
|Any other actions or
statements:||
|Physical appearance:||

Referred for _______ alcohol test ____________ drug test _____________ both

Employee: _________agreed to go ____________ Refused to go

Information recorded by: ______________________________________________

Retention Schedule: Upon completion, this form shall be retained in the local personnel office for two (2) calendar
years.

Attachments (12)

  1. Sample Letter - Alcohol/Drug Suspension with Pay (Classified/Unclassified Employee) (223 words)
  2. Sample Letter - Alcohol Dismissal (Classified Employee) (175 words)
  3. Sample Letter - Alcohol Dismissal (Unclassified Employee) (166 words)
  4. Sample Letter - Drug Dismissal (Unclassified Employee) (246 words)
  5. Sample Letter Drug Dismissal (Classified Employee) (254 words)
  6. Alcohol and Drug Test Notification (Random) (270 words)
  7. Alcohol/Drug and CDL Drug Testing Log (82 words)
  8. Drug Test Awareness Statement/Notification (Pre-Employment) (220 words)
  9. On-Site Substance Abuse Screening Documentation Form (38 words)
  10. Withdrawal of Employment Offer Due to Positive Pre-Employment Drug Test (167 words)
  11. Withdrawal of Employment Offer for Refusal to Test_Failure to Remain or Appear for Pre-Employment Drug Test (190 words)
  12. Behavioral/Incident Documentation Form (for Reasonable Suspicion Drug and Alcohol Testing) (150 words)
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