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SUBSTANCE ABUSE POLICY DOCUMENT NO.: EHS-000146 REV #: 1 <br />Date of Issue: 8/23/2016 Next Rev.: <br />EH&S Procedures Issued By: Corporate Safety Director 6/15/2021 <br />Date of Approval: 6/15/2017 <br />Standard Owner: EH&S Department q roved B : Safet <br />Date: Time: <br />Name: <br />Appendix — C: <br />Reasonable Suspicion Report <br />Interview Location: <br />Address: <br />Payroll/Badge #: SS#: <br />Interview: <br />Are you ill? . Have you been to a doctor/dentist recently? <br />Are you presently taking medication? If so, what?_ <br />Last dose: AM/PM Do you have diabetes? Are you taking insulin?_ <br />Are you hurt? Where? <br />Examination: (Check words describing observed conditions. Add other words which may be <br />appropriate.) <br />Breath: Odor of alcohol or liquor: ❑ None ❑ Faint ❑ Moderate ❑ Strong <br />Attitude: ❑ Polite ❑Excited ❑ Hilarious ❑ Talkative <br />❑ Sleepy ❑ Other ❑ Cooperative ❑ Indifferent <br />Carefree <br />❑ <br />Antagonistic <br />❑ Combative <br />❑ Insulting <br />Eyes: ❑ Normal <br />Pupils: ❑ Normal <br />❑ Watery <br />❑ Dilated <br />❑ Bloodshot <br />❑ Constricted <br />❑Poor Reaction to Light <br />Balance: ❑ Fair <br />❑ Falling <br />❑ Sure <br />❑Swaying <br />❑ Other <br />❑Wobbling <br />❑ Swaying Knees <br />Walking: ❑Fair <br />❑ Sure <br />❑Swaying <br />❑Uncertain ❑Stumbling <br />❑ Other <br />❑ Staggering ❑ Falling <br />Speech: ❑ Fair ❑ Slurred ❑ Stuttering ❑confused incoherent <br />❑ Choice of words, clearness and correctness of enunciation abnormal for individual. <br />What first led supervisor to suspect influence of intoxicant? <br />Disposition or action: <br />Interviewed by: Date: Time: <br />Decision concurred with by: <br />Name: Title: <br />Page 16 of 22 <br />