Page 146 - Personnel Policy and Procedures Manual

***PERSONAL AND CONFIDENTIAL***

FOR-CAUSE/REASONABLE SUSPICION DRUG TEST AUTHORIZATION FORM

FOR-CAUSE TEST is requested for:
Print Employee Name: Payroll #:

Department: Job Title

Physical Signs or Symptoms

 1. Possessing, dispensing, or  8. Loss of physical control, poor  15. Dilated or constricted
using prohibited substance. coordination, unsteady gait. pupils or unusual eye movement

 2. Slurred or incoherent speech  9. Extreme fatigue or sleeping  16. Excessive sweating or
on the job. clamminess of skin
 3. Bloodshot or watery eyes
 10. Flushed or very pale face  17. Shaking hands or body
 4. Odor of alcohol tremors.
 11. Nausea or vomiting
 5. Odor of Marijuana  18. Dry mouth
 12. Disheveled appearance or
 6. Runny nose or sores around out of uniform  19. Breathing irregularity or
nostrils. difficult breathing
 13. Dizziness or fainting
 7. Puncture marks or "tracks"  20. Inappropriate wearing of
 14. Highly excited or nervous sunglasses.

 21. Other (describe below)
3. Has there been a change to the employee's quality and quantity of work?  NO If so describe:

4. Has the employee's work relationships changed with fellow employees?  NO If so, describe:

5. Does the employee appear to "bring his personal/family problems" to work more than usual?  NO If so,
describe:

6. Have you noticed any recent changes in personality, moods, or behavior? NO If so, describe:

FORM SA-4 Page 1 of 2

All Rights Reserved – As approved by the Commission on 05-07-2019 146 | P a g e