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FITNESS FOR DUTY <br />REASONABLE CAUSE OBSERVATION DOCUMENTATION <br />All employees, including yourself, occasionally exhibit some performance problems and behavior changes. Sometimes <br />these problems and changes cause concern that an employee may be unfit to perform the employee’s regular duties as a <br />result of substance abuse. Below is a checklist of observations for you to use in determining when there is a reasonable <br />cause for such concern and possible substance testing. <br /> NAME________________________ LOCATION _________________________ <br /> DATE ________________________ TIME ______________________________ <br />The onset of one or more of the following observations may be cause for substance abuse testing: <br />SPEECH AWARENESS BALANCE PHYSICAL INDICATORS <br />___ Incoherent ___ Confused ___ Swaying ___ Pupils dilated/red eyes <br />___ Muddled___ Sleepy___ Staggering ___ Cold Sweats/tremors <br />___ Slurred ___ Erratic Behavior ___ Falling ___ Alcohol/marijuana odor <br />When you observe behaviors that may interfere with the employee’s performance, you shall note and document your <br />observations. The employee shall be counseled about any performance problems, and any explanations volunteered <br />or offered by the employee shall be noted. Although work related performance or behavior problems might be cause <br />for substance abuse testing, continued work related performance and behavior problems might result in <br />reassignment, or discipline up to and including termination of employment. <br />WORK OBSERVATIONS <br />_____ Unexplained or excessive absenteeism or tardiness <br /> _____ Unexplained or excessive absence from work area <br /> _____ Frequent trips to water cooler or restroom <br /> _____ Difficulty in understanding/recalling instructions <br /> _____ High frequency of incident occurrence <br />MOODS PHYSICAL INDICATORS <br />_____ Withdrawn /sad/morbid _____ Rapid breathing <br />_____ Mood swings high and low _____ inappropriate wearing of sunglasses <br />_____ Nervousness/agitation _____ Neglect of personal hygiene <br />COMMENTS:___________________________________________________________ <br /> ___________________________________________________________ <br />To the best of my knowledge and belief, This report represents the actions, appearances and/or conduct observed by me and upon <br />which I base my decision to suggest said employee be tested or be further evaluated by a supervisor. <br />EMPLOYEE: _________________________SUPERVISOR: ________________________ <br /> <br />WITNESS: ____________________________ <br />WRITTEN SAFTEY PROGRAM Page | 247 <br /> <br />