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ATTACHMENT 3 <br />SUPERVISOR DRUG AND/OR ALCOHOL CHECKLIST <br />Supervisor Drug and/or Alcohol Checklist <br />Question Yes No <br />I. Smell of alcohol on breath of person? <br />2. Speech: <br />• Slurred? <br />❑ <br />❑ <br />• Confused? <br />❑ <br />❑ <br />• Fragmented? <br />❑ <br />❑ <br />• Slow? <br />❑ <br />❑ <br />• Unusually soft? <br />❑ <br />❑ <br />• Unusually loud? <br />3. Disorientation — Is the contractor confused about: <br />• Where he or she is? <br />❑ <br />❑ <br />• What day it is? <br />❑ <br />❑ <br />• What time it is? <br />❑ <br />❑ <br />4. Apparent inability to focus on work? <br />5. Unusual or unexplained resistance to authority or refusal to follow reasonable directions? <br />6. Lack of motor coordination? <br />7. Mood: <br />• Belligerent? <br />❑ <br />❑ <br />• Moody? <br />❑ <br />❑ <br />• Ecstatic? <br />❑ <br />❑ <br />• More nervous than usual? <br />❑ <br />❑ <br />• Giddy? <br />F1 <br />❑ <br />• Talkative? <br />❑ <br />❑ <br />• Drowsy? <br />8. Skin color: <br />• Pale? <br />❑ <br />❑ <br />• Flushed? <br />❑ <br />❑ <br />9. Excessive perspiration? <br />10. Excessive trips to the restroom? <br />11. Bloodshot eyes? <br />12. Dilated pupils? <br />13. Pinpoint pupils? <br />14. Traces of alcohol in containers? <br />15. Confession by contractor that he/she was drinking alcohol or ingesting drugs? <br />16. Confirmation by other contractors or employees? <br />17. Presence of substances with the appearance of drugs? <br />18. Presence of drug paraphernalia? <br />19. Smell of marijuana? <br />20. Congregation of contractors in remote areas of the companies, facilities, or in areas not <br />❑ <br />❑ <br />usually frequented by contractors? <br />21. Weariness, fatigue, or exhaustion? <br />22. Deteriorating physical appearance? <br />23. Yawning excessively? <br />©National Compliance Management Service (NCMS): NCMS Model - Revised June 2021 16 <br />