Belte r r a Cor p or at ion S afety M an ual D oc I D C H S M BE L 2 0 1 7 Pa g e 4 82 of 53 8 R E A SON A B L E C A U SE A N D POST I N C I D EN T D R U G A N D A L C OH OL T EST I N G R EF ER R A L C H EC K L I ST Doc u m e n t Identif icat ion F R M 025 P age Nu m b e r 1 of 2 Doc u m e n t C r e ation Dat e J a nua r y 1 2013 Im p le m e n tat ion Dat e J a nua r y 1 2013 To e stablis h re a sona bl e groun ds t o pro c e e d with D rug a nd Alc ohol t e sti n g it is no t nec e ssar y to hav e a major it y of the que sti ons t icke d of f a s y e s This che c kli st i s si mpl y a tool to help a s se ss t he sit ua ti on The ba sic que sti on is g iven the sit ua ti on Ar e the re r e a son a ble g roun ds ba se d on th e a c ti ons a ppe a r a nc e o r c onduc t of the e mpl o y e e while on d ut y to indi c a te th e use of Dr u g s a ndor A lcohol W he re pra c ti c a ble the S upe rvisor will e ng a ge a Hum a n R e sourc e s r e pre s e ntative or a se c ond S upe rvisor on si te to c onfir m t he a ssessm e nt of the Empl o y e e s a c t ions a pp e a ra n c e a nd c onduc t Que sti on Ye s No Que sti on Ye s No S mell of A lcohol on br e a th of Emplo y e e P re se nc e o f substanc e s w it h S pe e c h Appe a r a nc e to D ru g s S lurr e d Dr u g P a ra ph e rna li a C onfuse d S mell of ma rijua na F ra g ment e d C ha ng e s in a ppe a ra nc e a fte r lunc h bre a k S low W e a rine ss fa ti g ue ex ha usti on Unusua ll y soft De ter ior a ti ng ph y sic a l a p pe a ra n c e Unusua ll y loud Ya wnin g e x c e ssi ve l y Disorie ntation I s the e m plo y e e c onfus e d a bout B lank star e or e x pre ssi on W he re he she is S udde n a ndor unpr e dict a ble c ha n ge in e ne r g y W ha t da y is i t Unusua ll y e ne r ge ti c W ha t t im e it is S ha king or tr e mbl ing of ha nds Appa re nt i na bil it y to foc us on wor k S ung lasse s wor n a t i na pp ropr iate ti mes Unusua l or une x plaine d r e sis tanc e to a uthorit y or re fus a l t o follow r e a sona bl e dire c ti ons S e e n c on g re ga ti ng with other s in re mot e a re a s o r a r e a s not usua ll y fr e que nt e d L a c k of motor c oo rdina ti on W it hdra wa l and a voidan c e of pe e rs Mood C ompl a int s fr om co wor ke rs B e ll iger e nt Ex c e ssi ve a bse ntee ism e spe c iall y Monda y s F rida y s d a y s be for e o r a ft e r holi da y s or p a y da y s Mood y Ec static Una uthoriz e d or u nsc he d uled a bse nc e s More ne rvous tha n usu a l P rolong e d lunch hou rs Gidd y Unusua ll y hi g h incide n c e of c olds flu upse t st omac hs a nd he a d a c he s S kin C olor P a le B re a thi ng dif fic ult ies F lushed Unusua l snee z ing nas a l conge sti on Ex c e ssi ve pe rspira ti on Ne e dle ma rks on a rms Ex c e ssi ve trips t o the r e st room Une x plaine d de pa rtur e s f rom w ork o r job ar e a