403.7E4 - Drug and Alcohol Testing Program Acknowledgement Form

I, ( ______________________________________________________ ), have received a copy, read and
Name of Employee

understand the Drug and Alcohol Testing Program policy and its supporting documents. I have also read and

understand the “Drug and Alcohol Training Handbook” provided to me by the district. I consent to submit to the

drug and alcohol testing program as required by the Drug and Alcohol Testing Program policy, its supporting

documents, regulations and the law.

I understand that if I violate the Drug and Alcohol Testing Program policy, its supporting documents, regulations

or the law, I may be subject to discipline up to and including termination.

I also understand that I must inform my supervisor of any prescription medication I use when requested. I further

understand that drug and alcohol testing records about me are confidential and may be released in accordance with

this policy, its supporting documents, regulations or the law.

_______________________________________________ _____________________________
(Signature of Employee) (Date)

_______________________________________________ _____________________________
(Witness/Transportation Director) (Date)

dawn.gibson.cm… Mon, 02/15/2021 - 11:52

403.7E5 - Drug and Alcohol Reasonable Suspicion Observation Form

This form must be completed by each trained employee observing the driver suspected of drug use and/or alcohol

misuse by behavior, speech and/or odor while on duty, the earlier of within 24 hours or the determination of reasonable suspicion or prior to receiving the test results. The observations must be specific, contemporaneous and articulable concerning the appearance, behavior, speech and body odor of the driver.

An example of an appropriate observation statement is, “The driver entered the bus barn slowly and held onto the bus until the driver reached the bus door,” rather than, “The driver came to work stoned and could not walk without holding onto the bus for support.”

Employees must notify the director of transportation about the situation. The director of transportation will notify the superintendent and they will contact law enforcement to assist with the investigation.

_____________________________________________ ________________________
Employee’s Name Date of Observation

Time of Observation: From __________ a.m./p.m. to __________ a.m./p.m.

Location: ______________________________________________________________

Observed personal behavior: (check all appropriate items)

Speech: ___Normal ___Incoherent ___Confused

___Slurred ___Whispering ___Silent

Balance: ___Normal ___Swaying

___Staggering ___Falling

Walking and Turning: ___Normal ___Stumbling ___Swaying

___Arms raised for balance ___Reaching for support

Awareness: ___Normal ___Confused ___Paranoid

___Sleepy or stupor ___Lack of coordination

Odor: ___Normal ___Alcohol ___Burned rope

Other observed behavior/odor:

____________________________________________________________________________________________

Reasonable suspicion of current use or impaired by: ___Alcohol ___Drugs

Above behavior witnessed by:

_____________________________________________ ________________________
(Signature) (Date)

_____________________________________________ ________________________
(Signature) (optional) (Date)

dawn.gibson.cm… Mon, 02/15/2021 - 11:54