CITY COUNCIL AGENDA PACKET - Laserfiche WebLink

ATTACHMENT A 80 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: ______________________________________________________________________ Signature Print Name Title Date Time Page 274 of 674