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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 />_ <br />8. <br />Increasingly irritable of tearful <br />9, <br />Persistently boisterous or rambunctious <br />_ <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 />_ <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. PWYSICAL INDICATORS - <br />YES NO <br />1. <br />Smell of alcohol on breath or person? <br />2. <br />Speech: Slurred? <br />- Confused? <br />Fragmented? <br />Slow? _ <br />Unusually soft? <br />Unusually loud? _ <br />3. <br />Disorientation: Is employee confused about; <br />_ <br />�.. <br />Where he or she is? <br />What day it is? _ <br />Wlla(time it is? _ <br />4. <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 />tack of motor coordination <br />7. <br />Mood: Belligerent? _ <br />_ <br />Moody? <br />Ecstatic? _ <br />More nervous than usual? _ <br />Giddy? _ <br />Talkative? _ <br />Drowsy? _ <br />8. <br />Skin color: Pale? _ <br />_ <br />Flushed? <br />9. <br />Excessive perspiration? <br />_ <br />10. <br />Excessive trips to the restroom? <br />_ - <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 />C) NATIONAL COMPLIANCE <br />hIANAGEMENISERVICE, INC-(NCIAS) 2011 (airdefe 20211- The NCMS plan Is <br />the subject of a reglSterad <br />copyrighl and Is proteclad by copyrbld laws in the U.S. and elsorvhere. All n9hls <br />eserved. <br />58 <br />