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NOTE: Prepare this form every time a driver is suspected of drug and/or alcohol use by physical, behavioral, speech, or performance indicators that constitute a major change in the driver’s appearance, behavior, and/or performance of his/her job-related duties, which is the basis for performing a “reasonable suspicion” drug and/or alcohol test.
Drivers Name:
Date of Observation: month, day, year
Start of Observation:
End of Observation:
Observed Behavior: (Check all that apply)
Physical Indicators Behavioral Indicators
Dilated Pupils Chronic Redness of Eyes Depression Anxiety
Constricted Pupils Chronic Nasal Problems Moodiness Irritability
Drowsiness Odor of Marijuana Alienation Agitation
Cold Sweats Odor of Alcoholic Beverage Combativeness Restlessness
Tremors Noticeable Weight Loss Panic Reactions Euphoria
Excessive Yawning Loss of Appetite Neglect of Personal Hygiene
Rapid Breathing Ravenous Appetite
Dizziness Unsteady Walk/Stumbling
Speech Indicators Performance Indicators
Thick Rapid Unable to Concentrate
Slurred Incoherent Errors in Judgement
Excessively Talkative Impaired Reasoning
Other abnormal behavior observed:
Max 500; characters remaining:
To the best of my knowledge and belief, this report represents the physical, behavioral, speech, or performance indicators of the above-named driver, observed by me and upon which I base my decision to require said driver to submit to a reasonable suspicion:
Choose from one of the following:
The above behavior has been witnessed by:
X_________________________ X_________________________
Signature of Supervisor or Company Official Signature of Supervisor or Company Official
__________/___________/_________ __________/___________/_________
Date Date

| 15.05.2006 |