Laserfiche WebLink
REPORT OF REASONABLE CAUSE/SUSPICION <br />Documentation of observations must be completed within 24 hours of observations. Supervisory or company <br />officials documenting reasonable cause/suspicion for DOT purposes musf have completed appropriate training for <br />dete r mi ni ng re a son able c au se/su spi cion. <br />Employee's Name <br />Name of lndividual Witnessing and Documenting ConducUBehavior: <br />Witness's Relationship to the Employee: <br />Date and Time of Report <br />Where did Reasonable Cause/Suspicion occur? <br />Date and Time of Occurrence: <br />Other Observers: <br />Description of what was observed (detail specific behavior and appearance. See list on back of this form for <br />assistance in detailing the observation and/or behavior. ltems listed may be indicated as observations by placing <br />an X in the box provided and specific observations circled for documentation purposes.) <br />Was an attempt made to discover the existence of an explanation other than substance abuse? . ( )Yes ( )No <br />lf Yes, explain <br />Were there any signs or complaints of illness or injury? ( )Yes ( )No <br />lf Yes, explain <br />ls employee in a "safety sensitive function"? ( )Yes ( )No <br />lf yes, explain function <br />Witness's Opinion: <br />Apparent Effects of Drug/Alcohol Use ( )None ( )Slight ( )Obvious ( )Extreme <br />Confidential information is documented in this statement. Drug or alcohol abuse information is not to be reported <br />or repeated, under any circumstances, to anyone other than those individuals outlined in the Controlled <br />Substances/Alcohol Policy. <br />Documentation of the employee's conduct shall be prepared and signed by the witness within 24 hours of the <br />observed behavior or before the results of the test are released, whichever is earlier. This form is to be submitted <br />to the Safety Director for review and action. <br />Signature of Witness <br />APPENDIXG-Pagel