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ATTACHMENT A <br />OBSERVATION OF IN] PAIRMENT REPORT <br />REASONABLE SUSPICION RECORD <br />Employee Name: Employee ID No. _ <br />Observation Date: Time: (from a.m./p.m. to a.m./p.m.) <br />Location: <br />Street City State Zip <br />This form is used to help determine if there is reasonable suspicion to believe a Covered Employee <br />is impaired by alcohol or drugs while on the job and to document pertinent findings. Reasonable <br />suspicion must be based on specific contemporaneous, articulable observations concerning the <br />appearance, behavior, speech or body odors of the person suspected of being impaired by alcohol <br />or drugs in violation of the LPFD policy. <br />OBSERVATIONS: <br />Detail the specific facts, symptoms and observations that form the basis for your determination <br />that the Covered Employee is impaired by alcohol or drugs while on the job. <br />TRAINED EMPLOYEE COMPLETING THE ASSESSMENT: <br />Signature Print Name <br />CONFIRMING WITNESS: <br />Concur is the above findings. <br />Signature <br />APPROVED BY: <br />Signature <br />Print Name <br />Rank Date Time <br />Rank Date Time <br />Print Name Title Date Time <br />72 <br />