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Supervisor Drug and/or Alcohol Checklist <br />Question Yes No <br />24. Blank stare or expression? <br />25. Sudden and/or unpredictable change in energy level? <br />26. Unusually energetic? <br />27. Shaking or trembling of hands? <br />28. Sunglasses worn at inappropriate times? <br />29. Changes in appearance after lunch break? <br />30. Withdrawal and avoidance of peers? <br />31. Complaints from co-workers? <br />32. Excessive absenteeism, especially Mondays, Fridays and days before or after holidays or <br />paydays? <br />❑ <br />❑ <br />33. Unusually high incidence of colds, flu, upset stomach, and/or headaches? <br />34. Unauthorized or unscheduled absences? <br />35. Breathing or swallowing difficulties? <br />36. Unusual sneezing / nasal congestion? <br />37. Needle marks on arms? <br />38. Prolonged lunch hours? <br />39. Tardiness? <br />40. Unexplained departures from work or disappearances from the job area? <br />41. More than average number of job -related mistakes injuries or accidents? <br />42. Decrease in efficiency or productivity? <br />43. Careless operation of equipment? <br />44. Careless performance of job? <br />©National Compliance Management Service (NCMS): NCMS Model - Revised June 2021 17 <br />