Reasonable Suspicion Observation Checklist

• Conducted on

  Date

• Prepared by

• Location
  Address

• Employee Name

• Period of Evaluation

• SUPERVISOR #1 Name, Telephone #

• SUPERVISOR #2 Name, Telephone #

• This checklist is intended to assist a supervisor in referring a person for drug testing. Has the employee manifested any of the following behaviors? Indicate (D) if documentation exists

• This checklist only provides possible indicators of substance use or abuse. It is not intended to be an exclusive list. Furthermore, an affirmative response to one or more questions does not necessarily indicate that reasonable suspicion exists to test an employee. Reasonable suspicion testing based solely on the use of this checklist is not endorsed. Reasonable suspicion determination can only be made by supervisory personnel in a given situation.

A. QUALITY AND QUANTITY OF WORK

• 1. Clear refusal to do assigned tasks

  Yes

  No

  N/A

• 2. Significant increase in errors

  Yes

  No

  N/A

• 3. Repeated errors in spite of increased guidance

  Yes

  No

  N/A

• 4. Reduced quantity of work

  Yes

  No

  N/A

• 5. Inconsistent, “up and down” quantity/quality of work

  Yes

  No

  N/A

• 6. Behavior that disrupts work flow

  Yes

  No

  N/A

• 7. Procrastination on significant decisions or tasks

  Yes

  No

  N/A

• 8. More than usual supervision necessary

  Yes

  No

  N/A

• 9. Frequent, unsupported explanations for poor work performance

  Yes

  No

  N/A

• 10. Noticeable change in written or verbal communication

  Yes

  No

  N/A

• 11. Other (please specify)

B. INTERPERSONAL WORK RELATIONSHIPS

• 1. Significant change in relations with co-workers, supervisors, etc

  Yes

  No

  N/A

• 2. Frequent or intense arguments

  Yes

  No

  N/A

• 3. Verbal abusiveness

  Yes

  No

  N/A

• 4. Physical abusiveness

  Yes

  No

  N/A

• 5. Persistently withdrawn or less involved with people

  Yes

  No

  N/A

• 6. Intentional avoidance of supervisor

  Yes

  No

  N/A

• 7. Expressions of frustration or discontent

  Yes

  No

  N/A

• 8. Change in frequency or nature of complaints

  Yes

  No

  N/A

• 9. Complaints by co-workers or subordinates

  Yes

  No

  N/A

• 10. Cynical, “distrustful of human nature” comments

  Yes

  No

  N/A

• 11. Unusual sensitivity to advice or critique of work

  Yes

  No

  N/A

• 12. Unpredictable response to supervision

  Yes

  No

  N/A

• 13. Passive-aggressive attitude or behavior, doing things “behind your back”

  Yes

  No

  N/A

• CSUSA SA Policy December 1, 2016

  Yes

  No

  N/A

RESONABLE SUSPICION OBSERVATION CHECKLIST

• 1. Excessive unauthorized absences—number in last 12 months

  Yes

  No

  N/A

• 2. Excessive authorized absences—number in last 12 months

  Yes

  No

  N/A

• 3. Excessive use of sick leave in last 12 months

  Yes

  No

  N/A

• 4. Frequent Monday/Friday absences or other pattern

  Yes

  No

  N/A

• 5. Frequent unexplained disappearances

  Yes

  No

  N/A

• 6. Excessive “extension” of breaks or lunch

  Yes

  No

  N/A

• 7. Frequently leaves work early—number of days per week or month

  Yes

  No

  N/A

• 8. Increased concern about (actual incidents) safety offenses involving employee

  Yes

  No

  N/A

• 9. Experiences or causes job accidents

  Yes

  No

  N/A

• 10. Major change in duties or responsibilities

  Yes

  No

  N/A

• 11. Interferes with or ignores established procedures

  Yes

  No

  N/A

• 12. Inability to follow through on job performance recommendation

  Yes

  No

  N/A

D. PERSONAL MATTERS

• 1. Changes in or unusual personal appearance (dress, hygiene)

  Yes

  No

  N/A

• 2. Changes in or unusual speech (incoherent, stuttering, loud)

  Yes

  No

  N/A

• 3. Changes in or unusual physical mannerisms (gesture, posture)

  Yes

  No

  N/A

• 4. Changes in or unusual facial expressions

  Yes

  No

  N/A

• 5. Changes in or unusual level of activity—much reduced/increased

  Yes

  No

  N/A

• 6. Changes in or unusual topics of conversation

  Yes

  No

  N/A

• 7. Engages in detailed discussions about death, suicide, harming others

  Yes

  No

  N/A

• 8. Increasingly irritable or tearful

  Yes

  No

  N/A

• 9. Persistently boisterous or rambunctious

  Yes

  No

  N/A

• 10. Unpredictable or out-of-context displays of emotion

  Yes

  No

  N/A

• 11. Unusual fears

  Yes

  No

  N/A

• 12. Lacks appropriate caution

  Yes

  No

  N/A

• 13. Engages in detailed discussion about obtaining/using drugs/alcohol

  Yes

  No

  N/A

• 14. Has personal relationship problems (spouse, girl/boyfriend, children, in-laws)

  Yes

  No

  N/A

• 15. Has received professional assistance for emotional or physical problems

  Yes

  No

  N/A

• 16. Makes unfounded accusations toward others (i.e. has feelings of persecution)

  Yes

  No

  N/A

• 17. Secretive or furtive

  Yes

  No

  N/A

• 18. Memory problems (difficulty recalling instructions, data, past behaviors)

  Yes

  No

  N/A

• 19. Frequent colds, flu, or other illnesses

  Yes

  No

  N/A

• 20. Excessive fatigue

  Yes

  No

  N/A

• 21. Makes unreliable or false statements

  Yes

  No

  N/A

• 22. Unrealistic self-appraisal or grandiose statements

  Yes

  No

  N/A

• 23. Temper tantrums or angry outbursts

  Yes

  No

  N/A

• 24. Demanding, rigid, inflexible

  Yes

  No

  N/A

• 25. Major change in physical health

  Yes

  No

  N/A

• 26. Concerns about sexual behavior or sexual harassment

  Yes

  No

  N/A

• Other information / observations (please be specific, attach additional sheets as needed).

• SUPERVISOR #1 Date

  Date

• SUPERVISOR #2 Date

  Date