SUPERVISOR'S CHECKLIST FOR MAKING
REASONABLE CAUSE DETERMINATION

Employee's name__________________________________________________

Department______________________________________________________

Date(s)__________________________________________________________

KNOWING THE SIGNS

The indicators listed below are "warning signs" of drug and/or alcohol abuse and may be observed by supervisors:

Moods:

• Depressed
• Anxious
• Irritable
• Suspicious
• Complains about others
• Emotional unsteadiness (e.g., outbursts of crying)
• Mood changes after lunch or break

Actions:

• Withdrawn or improperly talkative
• Spends excessive amount of time on the telephone
• Argumentative
• Has exaggerated sense of self-importance
• Displays violent behavior
• Avoids talking with supervisor regarding work issues

Absenteeism:

• Acceleration of absenteeism and tardiness, especially Mondays, Friday, before and after holidays
• Frequent unreported absences, later explained as "emergencies"
• Unusually high incidence of colds, flus, upset stomach, headaches
• Frequent use of unscheduled vacation time
• Leaving work area more than necessary (e.g., frequent trips to water fountain and bathroom)
• Unexplained disappearances from the job with difficulty in locating employee
• Requesting to leave work early for various reasons

Accidents:

• Taking of needless risks
• Disregard for safety of others
• Higher than average accident rate on and off the job

Work Patterns:

• Inconsistency in quality of work
• High and low periods of productivity
• Poor judgment/more mistakes than usual and general carelessness
• Lapses in concentration
• Difficulty in recalling instructions
• Difficulty in remembering own mistakes
• Using more time to complete work/missing deadlines
• Increased difficulty in handling complex situations

Relationship to Others on the Job:

• Overreaction to real or imagined criticism (paranoid)
• Avoiding and withdrawing from peers
• Complaints from co-workers
• Borrowing money from fellow employees
• Persistent job transfer requests
• Complaints of problems at home such as separation, divorce and child discipline problems

OBSERVING AND DOCUMENTING CURRENT INDICATORS

Patterns of any of the above conduct or combinations of conduct may occur but must be accompanied by indicators of impairment in order to establish "reasonable cause." Please check all indicators listed below that are currently present:

     ____ Constricted pupils             ____ Drowsiness
     ____ Dilated pupils                 ____ Odor of alcohol
     ____ Scratching                     ____ Nasal secretion
     ____ Red or watering eyes           ____ Dizziness
     ____ Involuntary eye movements      ____ Muscular incoordination
     ____ Sniffles                       ____ Unconsciousness
     ____ Excessively active             ____ Inability to verbalize
     ____ Nausea or vomiting             ____ Irritable
     ____ Flushed skin                   ____ Argumentative
     ____ Sweating                       ____ Difficulty concentrating
     ____ Yawning                        ____ Slurred speech
     ____ Twitching                      ____ Bizarre behavior
     ____ Violent behavior               ____ Needle marks

     ____ Possession of paraphernalia (such as syringe, bent spoon,
          metal bottle cap, medicine dropper, glassine bag, paint can,
          glue tube, nitrite bulb, or aerosol can)

     ____ Possession of substance that appears to possibly be a drug
          or alcohol

     ____ Other ______________________________________________________

     _________________________________________________________________

     _________________________________________________________________

DETERMINING REASONABLE CAUSE

If you are able to document one or more of the indicators above, ask yourself these questions to establish reasonable cause:

Y  N

[ ] [ ] Has some form of impairment been shown in the employee's appearance, actions or work performance?

[ ] [ ] Does the impairment result from the possible use of drugs or alcohol?

[ ] [ ] Are the facts reliable? Did you witness the situation personally, or are you sure that the witness(es) are reliable and have provided firsthand information?

[ ] [ ] Are the facts capable of explanation?

[ ] [ ] Are the facts capable of documentation?

[ ] [ ] Is the impairment current, today, now?

Do NOT proceed with reasonable cause testing unless all of the above questions are answered with a YES.

TAKING ACTION

____ Reasonable cause established

____ Reasonable cause NOT established

Prepared by:

Supervisor's/Manager's Signature:__________________________________________________