SOP_NUMBER: 104.58-att-12
TITLE: Behavioral/Incident Documentation Form (for Reasonable Suspicion Drug and Alcohol Testing)
DIVISION: Administrative & Finance
TOPIC_AREA: 104 Policy-HR Appearance/Conduct/Evaluations
EFFECTIVE_DATE: 2020-08-19
WORD_COUNT: 150
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/175444
URL: https://gps.press/sop-data/104.58-att-12/

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

ATTACHMENTS:
  1. Sample Letter - Alcohol/Drug Suspension with Pay (Classified/Unclassified Employee)
     URL: https://gps.press/sop-data/104.58-att-1/
  2. Sample Letter - Alcohol Dismissal (Classified Employee)
     URL: https://gps.press/sop-data/104.58-att-2/
  3. Sample Letter - Alcohol Dismissal (Unclassified Employee)
     URL: https://gps.press/sop-data/104.58-att-3/
  4. Sample Letter - Drug Dismissal (Unclassified Employee)
     URL: https://gps.press/sop-data/104.58-att-4/
  5. Sample Letter Drug Dismissal (Classified Employee)
     URL: https://gps.press/sop-data/104.58-att-5/
  6. Alcohol and Drug Test Notification (Random)
     URL: https://gps.press/sop-data/104.58-att-6/
  7. Alcohol/Drug and CDL Drug Testing Log
     URL: https://gps.press/sop-data/104.58-att-7/
  8. Drug Test Awareness Statement/Notification (Pre-Employment)
     URL: https://gps.press/sop-data/104.58-att-8/
  9. On-Site Substance Abuse Screening Documentation Form
     URL: https://gps.press/sop-data/104.58-att-9/
  10. Withdrawal of Employment Offer Due to Positive Pre-Employment Drug Test
     URL: https://gps.press/sop-data/104.58-att-10/
  11. Withdrawal of Employment Offer for Refusal to Test_Failure to Remain or Appear for Pre-Employment Drug Test
     URL: https://gps.press/sop-data/104.58-att-11/
  12. Behavioral/Incident Documentation Form (for Reasonable Suspicion Drug and Alcohol Testing)
     URL: https://gps.press/sop-data/104.58-att-12/

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FULL TEXT:
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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,<br>other:|
|---|---|
|Eyes:|Bloodshot,  Glassy,   heavy eyelids,  fixed or dilated pupils,  normal,<br>other:|
|Speech:|Confused,  Stuttered,  thick tongued, mumbled,  slurred, normal,<br>other:|
|Attitude:|Excited,  indifferent, combative,  profane,  insulting,  sleepy, cocky,<br>talkative, normal, other:|
|Balance:|Falling,  swaying,  wobbling,  other:|
|Walking:|Falling, Swaying,  staggering,  stumbling,<br>other:|
|Turning:|Falling, Swaying,  staggering,  stumbling,<br>other:|
|Any other actions or<br>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.