Laserfiche WebLink
16, Confirmation by other employees? <br />17. Presence of substances with the appearance of drugs? <br />18, Presence of drug paraphernalia? <br />19. Small 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'tl <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 ne <br />SUPERVISOR 81 (print name) <br />SUPERVISOR tlf1 (signature/date) <br />SUPERVISOR 82 (print name) <br />SUPERVISOR $2 (signature/date) <br />Premium Concrete Services, Inc.- PHMSA QRUG/ALCOHOL PLAN <br />() NATIONAL COlAPLIAMCE MANAGEMENT SERVICE, INC (IJCM51201 I jripelale 20211_ The NCMS plan is <br />Ihtt snl,)oq of a rcglsloratl copyright and is proleGad by copyrlglil laws in Ilse U.S. anJ elsa�vhore. All rights <br />eaerved_ <br />