INTOXICATION AND SUBSTANCE ABUSE CHECKLIST

ASSOCIATE INFORMATION
NAME

BUSINESS UNIT

CLOCK #

SHIFT

DATE

COST CENTER

OBSERVATIONS

Breath

(apparent odor of alcohol or substance abuse):

None

Strong

Faint

Moderate

Bad Breath

Burnt rope

Eyes:
Bloodshot
Normal

Glassy
Fixed Pupils

Glazed
Watery
Difficulty focusing
Dilated Pupils
Heavy Eyelids

Speech:
Confused
Stuttered
Thick Tongued
Accent
Lacks Continuity
Loud
Slurred
Mush Mouthed
Talkative
Incomprehensible
Garbled
Normal
Cotton Mouthed
Mixed or Rapid Subject Change
Other ________

Attitude / Personality / Appearance / Demeanor:

Excited
Combative
Hilarious
Indifferent
Talkative
Insulting
Care Free
Cocky
Fearful
Cooperative
Profane
Polite
Body Odor
Dizzy
Uncharacteristically Passive
Sleepy
Stuporous
Forgetful
Depressed
Distorted Sense of Time
Nervous
Runny Nose
Nose Bleeds
Anxious
Paranoid
Flat Affect
Panicky
Chills
Disoriented Excessive
Perspiration
Lethargic
Needle Marks
Mood Swings
Nauseous
Argumentative
Poor Control
Warm Skin
Distorted Sight
Distorted Hearing
Distorted Self Image
Flaccid Appearance
Unconsciousness
Frequent Lip Licking
Excessively Active
Still
Lack of Interest
Chronic Sinus/Nasal Problem
Lack of facial expression or animation
Other ________

Difficulty Sitting

Unusual Action(s):
Hiccuping
Belching
Vomiting
Fighting
Sobbing / Crying
Laughing
Rigidity
Absenteeism
Unexplained Accident(s)
Bizarre or Reckless Behavior
Other _______

Balance / Body Movement / Proprioception:

Hesitant
Stumbling

Swaying
Staggering Falling
Needs support
Other _________

Wobbling

Document any other unusual actions or statements :

Document physical evidence of intoxication / substance abuse (alcohol

beverage, drug paraphernalia, actual controlled or drug substance) :

Document signs or complaints of associate illness or injury :

Document any witness statements / observations :

Suspicious of:

Alcohol Intoxication

Substance Abuse

Effects of alcohol intoxication / substance abuse :

None
Extreme

Fit for Duty:

Yes

Suspected

Slight

Obvious

No

Is associate agreeable to undergo alcohol / drug testing?

Yes

No

Note: UNION FACILITIES ONLY

Supervisor must offer associate union representation if associate is
undergoing alcohol / drug testing and discipline may result. Please indicate if
associate accepted or declined representation below:
Accept

Decline

Additional Comments:

HR Specialist Name:
__________________________________________________________________

Supervisor: ______________________________

Witness(es):

______________________________

Signature: ______________________________
______________________________

Time:

______________________________

______________________________

Revised 5/2010