Section 3 Personnel


Policy 3-2B APPENDIX B

CITY OF LAWTON
DRUG AND ALCOHOL FREE WORKPLACE POLICY
Appendix B

RASONABLE SUSPICIION OBSERVATION CHECKLIST
(Confidential)
When a drug test is ordered based on reasonable suspicion that an employee may have abused drugs or alcohol, the actions and behavior leading to the suspicion must be documented.  Actions which result in reasonable suspicion testing will occasionally be single actions, although for many employees there is a pattern of behavior which indicates a problem.  In either case, the supervisor is required to complete this or a similar checklist, giving specific information on what was done, the date it occurred, etc.


__________________________________        ______________________________________
               EMPLOYEE NAME                      PERIOD OF EVALUATION


__________________________________        ______________________________________
   SUPERVISOR #1 (Name and Title)                SUPERVISOR #2 (Name and Title)

Has the employee manifested any of the following behaviors?  Indicate “D” if documentation exits.
QUALITY AND QUANTITY OF WORK

YES    NO
____    ____    1.    Clear refusal to do assigned tasks.
____    ____    2.    Significant increase in errors
____    ____    3.    Repeated error in spite of increased guidance.
____    ____    4.    Reduced quantity of work.
____    ____    5.    Inconsistent, “up and down” quantity and quality of work.
____    ____    6.    Behavior that disrupts workflow.
____    ____    7.    More than usual supervision necessary.
____    ____    8.    Procrastination on significant decisions or tasks.
____    ____    9.    Frequent, unsupported explanations for poor work performance.
____    ____    10.    Noticeable change in written or verbal communication.
____    ____    11.    Other (please specify):
INTERPERSONAL WORK RELATIONSHIPS
YES    NO
____    ____    1.    Significant change in relations with co-workers, supervisors, others.
____    ____    2.    Frequent or intense arguments.
____    ____    3.    Verbal abusiveness.
____    ____    4.    Physical abusiveness.
____    ____    5.    persistently withdrawn or less involved with people.
____    ____    6.    Intentional avoidance of supervisor.
____    ____    7.    Expressions of frustration or discontent.
____    ____    8.    Change in frequency or nature of complaints.
____    ____    9.    Complaints by co-workers or subordinates.
____    ____    10.    Cynical, “distrustful of human nature” comments.
____    ____    11.    Unusual sensitivity to advice or critique of work.
____    ____    12.    Unpredictable response to supervision.
____    ____    13.    Passive-aggressive attitude or behavior, doing things “behind your back”.
GENERAL JOB PERFORMANCE
YES    NO
____    ____    1.    Excessive unauthorized absences – number in last 12 months __________.
____    ____    2.    Excessive authorized absences – number in last 12 months ____________.
____    ____    3.    Excessive use of sick leave in last 12 months – number of days_________.
____    ____    4.    Frequent Monday/Friday absences or other pattern.
____    ____    5.    Frequent unexplained disappearances from the work site.
____    ____    6.    Excessive “extensions” of breaks or lunch periods.
____    ____    7.    Frequently leaves work early – number of days per week or month______.
____    ____    8.    Increased concern about, or incidents of, safety violations involving the employee
____    ____    9.    Experiences or cause job accidents
____    ____    10.    Major change in duties or responsibilities.
____    ____    11.    Interferes with or ignores established procedures.
____    ____    12.    Inability to follow through on job performance recommendations.
PERSONAL MATTERS
YES    NO
____    ____    1.    Changes in or unusual personal appearance (Dress, Hygiene).
____    ____    2.    Changes in or unusual speech (incoherent, stuttering, loud).
____    ____    3.    Changes in or unusual physical mannerisms (gestures, posture).
____    ____    4.    Changes in or unusual facial expressions.
____    ____    5.    Changes in or unusual level of activity – much reduced_____or increased_____.
____    ____    6.    Changes in or unusual topics of conversation.
____    ____    7.    Engages in detailed discussions about death, suicide, or harming someone.
____    ____    8.    Increasingly irritable or tearful.
____    ____    9.    Persistently boisterous or rambunctious.
____    ____    10.    Unpredictable or out-of-context displays of emotions.
____    ____    11.    Unusual fears.
____    ____    12.    Lacks appropriate caution.  
____    ____    13.    Engages in detailed in discussion about obtaining or using drugs or alcohol.
____    ____    14.    Has personal relationship problems (spouse, girl/boyfriend, children, in-laws).
____    ____    15.    Has received professional assistance for emotional or physical problems.
____    ____    16.    Makes unfounded accusations toward others, i.e. has feeling of persecution.
____    ____    17.    Secretive or furtive.
____    ____    18.    Memory problems (difficulty recalling instructions, data, past behavior).
____    ____    19.    Frequent colds, flu, or other illnesses.
____    ____    20.    Comes to work with the odor of alcohol on breath.
____    ____    21.    Excessive fatigue.
____    ____    22.    Makes unreliable or false statements.
____    ____    23.    Unrealistic self-appraisal or grandiose statements.
____    ____    24.    Temper tantrums or angry outbursts.
____    ____    25.    Demanding, rigid, inflexible.
____    ____    26.Major change in physical health
____    ____    27.    Concerns about sexual behavior or sexual harassment.
Other information/observations (Please, be specific and attach additional sheets as needed):
______________________________________    ________________________________________
Signature of Supervisor #1                        Date    Signature of Supervisor #2                            Date