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_ 16. Confirmation by other 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 employees in remote areas of the company's facilities or in areas not <br />usually frequented by employees? <br />21. Weariness, fatigue, or exhaustion? <br />22. Deteriorating physical appearance? <br />E. PHYSICAL INDICATORS (Con't) <br />YES NO <br />23. Yawning excessively? <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. Breathing or swallowing difficulties? <br />31. Unusual sneezing/nasal congestion? <br />32. Needle marks on arms? <br />33. Prolonged lunch hours? <br />34. Tardiness? <br />Other information/observations - (Please be specific & attach additional sheet as needed). <br />SUPERVISOR #1 (print name) <br />SUPERVISOR #1 (signature/date) <br />SUPERVISOR #2 (print name) <br />SUPERVISOR #2 (signature/date) <br />Premium Concrete Services, Inc.- PHMSA DRUG/ALCOHOL PLAN <br />NATIONAL COMRLIANCE MANAGEMENT SERVICE, ING (NGM512011 (update'202n. Tlie NGMS plan Is <br />the subjocl of a rogisiorc�tl wpyright and is proleGatl by copyrlgfil lawsin Ilse U.S. and elsawRola. All rights <br />eserved <br />59 <br />