Condition of Employee Report Sample Clauses

Condition of Employee Report. Name of Observed Employee: Job Title: Observation Date/Day of Week: / Time Relieved of Duty: Location Relieved of Duty: APPEARANCE: BEHAVIOR: Glassy Eyes Yes No Blank Stare Yes No Bloodshot eyes Yes No Flushed face Yes No Alcohol smell Yes No Marijuana smell Yes No Altered appearance Yes No Slurred speech Yes No Confused speech Yes No Staggering Yes No Poor coordination Yes No Tremors/shakes Yes No Confused Yes No Disoriented Yes No Drowsiness Yes No MOOD: Sleeping Yes No Hearing things Yes No Mood changes Yes No Isolating Yes No Nervousness Yes No Belligerent Yes No Seeing things Yes No Blackouts Yes No OTHER: Aggressive Yes No Unusually quiet Yes No Unusually talkative Yes No Did employee provide reason(s) for his/her physical conditions? If so, provide reason(s): Was employee directed to take a breath and urinalysis test? Yes No Did employee refuse to undergo the breath and urinalysis test? Yes No Was employee informed of the consequences for refusing the test? Yes No Name of supervisor: Signature of supervisor: Date: Name of additional supervisor: Signature of additional supervisor: Date: Note: Observation by a second supervisor is recommend but not required. APPENDIX I APPENDIX I