REASONABLE SUSPICION DETERMINATION CHECKLIST
This checklist is to be completed whenever an incident or work-related accident has occurred and there is a reasonable
suspicion that the colleague is under the influence of alcohol and / or drug substances as defined in the Substance Abuse
Policy.
The Supervisor shall note all pertinent behaviour and physical signs or symptoms that led the Supervisor to reasonably
believe that the colleague has recently used or is under the influence of alcohol and / or drug substances. The Supervisor
shall mark each applicable item on this form and describe any additional facts or circumstances as noted.
Date of Incident or Work-related accident:
Time of Incident or Work-related accident:
___________________________________________
Colleague Name:
Employee Number:
Division / Branch:
Observing Supervisor’s Name:
Second observing Colleagues Name:
REASONABLE SUSPICION OBSERVATIONS
A.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
PHYSICAL SIGNS OR SYMPTOMS
Possessing, dispensing or using controlled substances.
Slurred, incoherent speech or loudness.
Unsteady gait or other loss of physical control; poor coordination.
Dilated or constricted pupils or unusual eye movement.
Bloodshot or watery eyes.
Extreme fatigue or sleeping on the job.
Excessive sweating or clamminess to the skin.
Flushed or very pale face.
Highly excited or nervous.
Nausea or vomiting.
Odour of alcohol.
Odour of marijuana.
Dry mouth (frequent swallowing / lip wetting).
Dizziness or fainting.
Shaking hands or body tremors / twitching.
Irregular or difficulty breathing.
Runny nose and / or sores around nostrils.
Inappropriate wearing of sunglasses.
Puncture marks or “tracks”.
Other.
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OCSA document number Document1
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29 April 2015
* Specify other physical signs or symptoms:
B.
1.
2.
3.
4.
5.
6.
UNUSUAL BEHAVIOUR
Verbal abusiveness.
Physical abusiveness.
Extreme aggressiveness or agitation.
Withdrawal, depression, mood changes or unresponsiveness.
Inappropriate response to questioning or instructions.
Other erratic or inappropriate behaviour* (e.g. hallucinations, disorientation, excessive euphoria,
confusion).
* Specify exact other behaviour:
C.
WRITTEN SUMMARY
Summarize the facts and circumstances of the accident or incident, colleague responses, Supervisor actions and any other
pertinent information not previously recorded on this form.
________________________________
NAME OF OBSERVER (SUPERVISOR)
_________________________________
SIGNATURE OF OBSERVER
_________________________________
NAME OF SECOND OBSERVER
_________________________________
SIGNATURE OF SECOND OBSERVER
Date:
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STATEMENT
Based upon my observations as noted on this checklist, I recommend that an alcohol / drug test be administered in
accordance with the Company Substance Abuse Policy.
The consequences of refusing testing have been explained to the affected colleague.
Signature of Line Manager:
SIGNED AGREEMENT FOR TESTING
I,
NAME OF EMPLOYEE
On
hereby agree to a
alcohol test
drug test
(date)
This test was will be conducted at the following location:
Employee refused to test:
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Yes
No
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29 April 2015