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50 <br /> <br /> <br /> <br />OBSERVATION OF IMPAIRMENT REPORT <br />REASONABLE SUSPICION RECORD <br /> <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 is <br />impaired by alcohol or drugs while on the job and to document pertinent findings. Reasonable suspicion <br />must be based on specific contemporaneous, articulable observations concerning the appearance, <br />behavior, speech or body odors of the person suspected of being impaired by alcohol or drugs in violation <br />of the LPFD policy. <br />OBSERVATIONS: <br />Detail the specific facts, symptoms and observations that form the basis for your determination that the <br />Covered Employee is impaired by alcohol or drugs while on the job. <br />____________________________________________________________________________________ <br />____________________________________________________________________________________ <br />____________________________________________________________________________________ <br />____________________________________________________________________________________ <br />____________________________________________________________________________________ <br />____________________________________________________________________________________ <br />__________________________________________ <br />TRAINED EMPLOYEE COMPLETING THE ASSESSMENT: <br /> <br />_____________________________________________________________________________ <br />Signature Print Name Rank Date Time <br /> <br />CONFIRMING WITNESS: <br /> <br />_____ Concur is the above findings. <br /> <br />______________________________________________________________________________ <br />Signature Print Name Rank Date Time <br /> <br /> <br />APPROVED BY: <br /> <br />_____________________________________________________________________________ <br /> <br />Page 327 of 674