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_ 10. <br />11. <br />12. <br />Major change in duties or responsibilities <br />Interferes with or ignores established procedures <br />Inability to follow through on job performance recommendation <br />D. PERSONAL MATTERS <br />YES NO <br />1. <br />Changes in or unusual personal appearance (dress, hygiene) <br />2. <br />Changes in or unusual speech (incoherent, stuttering, loud) <br />3. <br />Changes in or unusual physical mannerisms (gesture, posture) <br />4. <br />Changes in or unusual facial expressions <br />5. <br />Changes in or unusual level of activity -much reduced/increased <br />6. <br />Changes in or unusual topics of conversation <br />7. <br />Engages in detailed discussions about death, suicide, harming others <br />_ 8. <br />Increasingly irritable or tearful <br />9. <br />Persistently boisterous or rambunctious <br />10, <br />Unpredictable or out -of -context displays of emotion <br />11. <br />Unusual fears or lacks appropriate caution. <br />12. <br />Engages in detailed discussion about obtaining/using drugs/alcohol <br />13, <br />Has personal relationship problems (spouse, girl/boyfriend, children,. in-laws) <br />_ 14, <br />Has received professional assistance for emotional or physical problems <br />15. <br />Makes unfounded accusations toward others, i.e., has feelings of persecution <br />_ 16, <br />Secretive or furtive <br />_ 17. <br />Memory problems (difficulty recalling instructions, data, past behaviors) <br />18. <br />Frequent colds, flu, excessive fatigue, or other illnesses <br />19. <br />Makes unreliable or false statements <br />_ _ 20. <br />Unrealistic self -appraisal or grandiose statements <br />_ _ 21, <br />Temper tantrums or angry outbursts <br />_ _ 22. <br />Demanding, rigid, inflexible <br />_ _ 23. <br />Major change in physical health <br />24. <br />Concerns about sexual behavior or sexual harassment <br />E. PHYSICAL INDICATORS <br />YES NO <br />1. <br />Smell of alcohol on breath or person? <br />_ 2. <br />Speech: Slurred? <br />_ <br />Confused? <br />Fragmented? _ <br />Slow? <br />Unusually soft? _ <br />Unusually loud? <br />3. <br />_ <br />Disorientation: Is employee confused about; <br />Where he or she is? <br />What day it is? <br />What time it is? <br />4. <br />_ <br />Apparent inability to focus on work? <br />5. <br />Unusual or unexplained resistance to authority or refusal to follow reasonable directions? <br />6, <br />Lack of motor coordination <br />7. <br />Mood: Belligerent? <br />_ <br />Moody? <br />Ecstatic? <br />_ <br />More nervous than usual? <br />Giddy? _ <br />Talkative? <br />Drowsy? <br />8. <br />Skin color: Pale? <br />_ <br />Flushed? <br />_ _ 9. <br />_ <br />Excessive perspiration? <br />_ 10. <br />Excessive trips to the restroom? <br />11. <br />Bloodshot eyes? <br />_ _ 12, <br />Dilated pupils? <br />13. <br />Pinpoint pupils? <br />14. <br />Traces of alcohol in containers? <br />_ 15. <br />Confession by employee that he/she was drinking alcohol or ingesting drugs? <br />Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN <br />n NATIONAL COMPLIANCE <br />MANAGEMENT SERVICE, INC. (NCMS) 2011 (update 2021) The NCMS plan Is <br />the subject of a regislered copyright <br />and is protected by copyright laws in the LI S. and elssertere. All rights <br />resolved <br />fi�% <br />