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XIV* Appendix G <br />Reasonable Cause/Suspicion Observation Checklist <br />(STRICTLY CONFIDENTIAL) <br />EMPLOYEE: <br />SUPERVISOR #1, NAME AND TELEPHONE: <br />SUPERVISOR #2, NAME AND TELEPHONE: <br />PERIOD OF EVALUATION: <br />This <br />checklist is intended to assist a supervisor in referring a person for drug and/or alcohol testing. Has the employee manifested <br />any <br />of the following <br />behaviors? <br />Indicate (X) if observation and/or documentation exists. <br />A. <br />QUALITY AND <br />QUANTITY <br />OF WORK <br />YES NO <br />1. Clear refusal to do assigned tasks <br />2 Significant increase in errors <br />3. Repeated errors in spite of increased guidance <br />4. Reduced quantity of work <br />5. Inconsistent, "up and down" quantity/quality of work <br />6. Behavior that disrupts workflow <br />7. Procrastination on significant decisions or tasks <br />8. More than usual supervision necessary <br />9. Frequent, unsupported explanations for poor work performance <br />10.Noticeable change in written or verbal communication <br />B. INTERPERSONAL WORK RELATIONSHIPS <br />YES NO <br />1. Significant change in relations with co-workers, supervisors <br />2 Frequent or intense arguments <br />3. Verbal/Physical abusiveness <br />4. Persistently withdrawn or less involved with people <br />_ 5. Intentional avoidance of supervisor <br />_ 6. Expressions of frustration or discontent <br />_ 7. Change in frequency or nature of complaints <br />_ 8. Complaints by co-workers or subordinates <br />9. Cynical, "distrustful of human nature" comments <br />10. Unusual sensitivity to advice or critique of work <br />11. Unpredictable response to supervision <br />12, Passive -aggressive attitude or behavior, doing things "behind your back" <br />C. GENERAL JOB PERFORMANCE <br />YES NO <br />1. Excessive unauthorized absences -number in last 12 months <br />2. Excessive authorized absences -number in last 12 months <br />_ _ 3. Excessive use of sick leave in last 12 months <br />4. Frequent Monday/Friday absence or other pattern <br />5. Frequent unexplained disappearances <br />_ 6. Excessive "extension" of breaks or lunch <br />7. Frequently leaves work early -number of days per week or month <br />8. Increased concern about (actual incidents) safety offenses involving the employee <br />9. Experiences or causes job accidents <br />Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN <br />U NATIONAL COMPLIANCE MANAGEMENT SERVICE, INC. (NCMS) 2011 (update 2021). The NCMS plan is <br />the sudecl of a registered copyrlghl and is protected by copyright laws in the U.S. and elsewhere. All rights <br />reserved <br />