Page 149 - Personnel Policy and Procedures Manual

CONCERN: EAP SUPERVISORY REFERRAL FORM
- C O N F I D E N T I A L -
NOTE: NOT FOR INCLUSION IN PERSONNEL FILE - Please print or type
This form is to be used as a guide in determining the extent and exact nature of the decline of
your employee's job performance. Please review the form with your employee, and be sure that
both parties sign. Please call if you have any questions. Upon completion of the form please
forward to: CONCERN, Employee Assistance Program, 2610-B Commons Blvd,
Augusta, GA 30909
Telephone: 706-667-2353, Toll Free 1-888-667-2353, FAX: 706-667-2303

Name and Title of Employee :

Company: Augusta, Georgia Government Department:

CHANGES IN WORK BEHAVIOR
(√_) (Please explain in detail indicating when you first noticed changes.)

Frequent short absences

Tardiness

Unexplained disappearances from work
station:

Reduced quantity of work

Reduced quality of work

Erratic work performance

Missed deadlines

Complaints from fellow workers

Errors due to inattention or poor judgment

Repeated minor accidents on or off job

Inability to concentrate

Irritability:

Overreaction to criticism

FORM SA-5 Page 1 of 2

All Rights Reserved – As approved by the Commission on 05-07-2019 149 | P a g e