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XIV. Appendix G <br />Reasonable Cause/Suspicion Observation Checklist <br />(STRICTLY CONFIDENTIAL) <br />EMPLOYEE: <br />SUPERV1.50R Ok1, NAME AND TELEPHONE: <br />SUPERVISOR Oft, NAME AND'fELEPHONE: <br />PERIOD OF EVALUATION: <br />This <br />checklist Is Intended to assist a supervisor in referring a person for drug and/or alcohol <br />testing: <br />Has the eirtployee manifested <br />any <br />of the following behaviors? Indicate (X) if observation and/or documentation exists, <br />A. nU,ALITY AND QUANTITY 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 RELATIONSNIYS <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 Persistently withdrawn or less Involved with people 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 f(uslration 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 altitude 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 aulhorizetl absencesnumber 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 />(!) NATIONAL COMPLIANCE MANAGEMENT SERVICE, INO (NCMS) 2011 (uprlaln 2021). Tile MOM$ planet <br />the subject of a registered copydghl and is protected by copyrlghl laws in the U 5. and elsewporc- All liable <br />reserved. 57 <br />