Reasonable Suspicion Observation

State Abbreviation:
MN
WI
SD
ND
Purpose: This form is designed to document observations made by a supervisor when there is reasonable suspicion that an employee is under the influence of drugs or alcohol. It ensures that all necessary details are recorded accurately and objectively to maintain a safe and compliant workplace.

Instructions: Supervisors should complete this form immediately after observing behavior or physical signs that raise concerns about an employee's fitness for duty. Provide detailed descriptions and avoid subjective language. This documentation will be used to determine the appropriate course of action and to support any necessary interventions.
Branch Location:*
Employee's Name:*

First NameLast Name
Observation Date and Time:*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location:*
Supervisor's Name:*

First NameLast Name
How long has the employee worked for the company?*
Was the employee involved in an accident or unsafe activity?*

YesNo
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Please describe accident or unsafe activity:*
Extent of injury to persons/property:*
Was there evidence of negligence/carelessness (please explain):*
List Witnesses:*
CAUSE OF SUSPICION:
Observed possession or use of a controlled substance and/or paraphernalia?*

YesNo
If yes, Please explain:*
Observed abnormal or erratic behavior?*

YesNo
Appearance:*

NormalDisheveledProfuse SweatingDilated PupilsBloodshot EyesUnable to Consistently Open EyesWater Eyes / FlushedPuncture MarksTremors or ShakingBodily OdorInappropriate Use of SunglassesOther
Speech:*

NormalConfusedSlurredMumbledIncoherentSlowedStutteredSilentShoutingIrritableRamblingOther
Awareness:*

NormalDisorientedParanoidEuphoricSadConfusedDrowsyHyperactiveLethargicOther
Breath*

Alcohol OdorVomit OdorMarijuana Odor
Attitude / Demeanor:*

NormalExcitedCare-FreeCooperativeCombativeTalkativeProfaneCalmInsultingPoliteMood SwingsViolentIrritableAngryOther
Motor Skills / Balance / Agility:*

NormalSwayingFallingUnsteadyNeeds SupportStaggeringShakySlow / DelayedOther
Other:

Employee's attendance has declinedEmployee has exhibited a change in performanceEmployee has exhibited a change in demeanor or behaviorOther
Indicate other unusual actions, behavior, or statements:
Supervision Opinion

The observable behaviors noted cause me to believe there is a potential safety concern and/or violation of the Company’s Drug and Alcohol Policy. If I believe this to be an immediate concern, I should stop the employees from working and prevent them from operating equipment where there would be a foreseeable danger. Based upon my observation, as noted in this document, I recommend that a drug and/or alcohol test be administered.
Supervisor Name:*

First NameLast Name
Date*

MonthDayYear
Date
Signature:*

Clear
Should be Empty:

CAUSE OF SUSPICION:

More Forms:

Documents: