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    Employee Observation Checklist

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    soran salimiyan
    The document appears to be an employee observation checklist used to document behaviors that may indicate drug or alcohol use, with sections to record the employee's name, social security number, date, time, and specific observable behaviors and characteristics. The behaviors listed include drowsiness, disorientation, odor of alcohol, slurred speech, aggressive behavior, work errors, and more. The form is to be completed by an observer and include their signature and title as well as a witness signature and title.

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    Employee Observation Checklist

    Uploaded by

    soran salimiyan
    3 views2 pages
    The document appears to be an employee observation checklist used to document behaviors that may indicate drug or alcohol use, with sections to record the employee's name, social security number, date, time, and specific observable behaviors and characteristics. The behaviors listed include drowsiness, disorientation, odor of alcohol, slurred speech, aggressive behavior, work errors, and more. The form is to be completed by an observer and include their signature and title as well as a witness signature and title.

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    The document appears to be an employee observation checklist used to document behaviors that may indicate drug or alcohol use, with sections to record the employee's name, social security number, date, time, and specific observable behaviors and characteristics. The behaviors listed include drowsiness, disorientation, odor of alcohol, slurred speech, aggressive behavior, work errors, and more. The form is to be completed by an observer and include their signature and title as well as a witness signature and title.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    3 views2 pages

    Employee Observation Checklist

    Uploaded by

    soran salimiyan
    The document appears to be an employee observation checklist used to document behaviors that may indicate drug or alcohol use, with sections to record the employee's name, social security number, date, time, and specific observable behaviors and characteristics. The behaviors listed include drowsiness, disorientation, odor of alcohol, slurred speech, aggressive behavior, work errors, and more. The form is to be completed by an observer and include their signature and title as well as a witness signature and title.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 2

    Employer Name

    Employee Health Services

    Employee Observation Checklist

    Employee Name: Department:

    Social Security #: Date: Time:

    Behaviors exhibited for suspicion of drug and/or alcohol use:

    Drowsiness or sleepiness
    Disorientation to person, place, or time
    Odor of alcohol on breath
    Slurred and/or incoherent speech
    Unusually aggressive or violent behavior
    Avoids associates
    Unexplained work errors or lack of reasonable judgement
    Failure to follow instructions/complete tasks
    Unexplained change of mood
    Unexplained or frequent accidents or injuries
    Lack of manual dexterity and/or coordination in walking
    Glassy, red eyes
    Repeated inability to concentrate
    Excessive absenteeism/tardiness

    Other observations:

    (Complete the second page of this form)


    Specific Observations:

    Walking/Standing
    unsteady swaying unable to stand
    staggering holding on unable to walk
    stumbling rigid

    Face Breath
    normal no alcoholic odor candy
    pale faint alcoholic odor mints
    flushed alcoholic odor other:
    perspiration chewing gum

    Eyes
    normal droopy pupils constricted
    blood shot watery eyes closed
    sleepy pupils dilated

    Speech
    normal shouting silent
    slurred profanity whispering
    slow slobbering incoherent

    Demeanor
    cooperative hyperactive fighting
    calm threatening talkative
    crying sarcastic sleepy
    excited hostile silent

    Other:

    Form completed by:

    Signature: Print Name:

    Title:

    Witness: Print Name:

    Title:

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