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G.O.#: EFFEC. DATE: PREV. DATE: Page 12 of 12 Pages 4894-5387-2224 v2 49 OBSERVATION OF IMPAIRMENT REPORT REASONABLE SUSPICION RECORD Employee Name: ___ Employee ID No. ___________ Observation Date: ____________ Time: (from a.m./p.m. to ______a.m./p.m.) Location: _____________________________________________________________________ Street City State Zip This form is used to help determine if there is reasonable suspicion to believe a Covered Employee is impaired by alcohol or drugs while on the job and to document pertinent findings. Reasonable suspicion must be based on specific contemporaneous, articulable observations concerning the appearance, behavior, speech or body odors of the person suspected of being impaired by alcohol or drugs in violation of the LPFD policy. OBSERVATIONS: Detail the specific facts, symptoms and observations that form the basis for your determination that the Covered Employee is impaired by alcohol or drugs while on the job. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ TRAINED EMPLOYEE COMPLETING THE ASSESSMENT: _____________________________________________________________________________ Signature Print Name Rank Date Time CONFIRMING WITNESS: _____ Concur is the above findings. ______________________________________________________________________________ Signature Print Name Rank Date Time APPROVED BY: _____________________________________________________________________________