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)
