REASONABLE SUSPICION REPORT FORM. This checklist is intended to assist a supervisor in referring a person for reasonable suspicion/cause drug and alcohol testing. The supervisor must identify at least three (3) contemporaneous indicia of impairment in two separate categories (e.g., Speech and Balance) in Section II, and fill out the Section III narrative. In the alternative, the supervisor must identify one of the direct evidence categories in Section I, and fill out the Section III narrative. ~Please print information~ Employee Name: Department: ; Division and Work Location: Date and Time of Occurrence: ; Incident Location:
REASONABLE SUSPICION REPORT FORM. This checklist is intended to assist a supervisor in referring a person for reasonable suspicion/cause drug and alcohol testing. The supervisor must identify at least three (3) contemporaneous indicia of impairment in two separate categories (e.g., Speech and Balance) in Section II, and fill out the Section III narrative. In the alternative, the supervisor must identify one of the direct evidence categories in Section I, and fill out the Section III narrative. ~Please print information~ Employee Name:
REASONABLE SUSPICION REPORT FORM. Date: Location of incident/accident: Time: Accident related injuries? Yes No (circle) If yes, provide details. Provide a brief summary of accident: Description of other party(s) involved: Police at scene? Yes No (circle) If yes, provide jurisdiction: Name (Supervisor/Manager) Name (Supervisor/Manager) Date Date
