Page 148 - Personnel Policy and Procedures Manual

PAGE 2 FOR-CAUSE REASONABLE SUSPICION DRUG TEST AUTHORIZATION FORM

NATURE OF INCIDENT/CAUSE FOR SUSPICION

 1. Observed possession or use of a prohibited substance

 2. Apparent drug or alcohol intoxication.

 3. Observed abnormal or erratic behavior.

 4. Other:

2. Test requested by:

Signature Date:

Printed Name: Payroll #:

Job Title: Department:

3. TEST AUTHORIZED BY:

Signature: Date:

Printed Name: Empl #:

Job Title: Department:

Additional Information

FORM SA-4 Page 2 of 2

All Rights Reserved – As approved by the Commission on 05-07-2019 148 | P a g e