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Employee’s Name Date of Observation
Time of Observation From To
Observed Personal Behavior (check all appropriate items)
Speech _____Normal _____Incoherent _____Confused _____Loud
_____Slurred _____Whispering _____Silent _____Disruptive
Balance _____Normal _____Swaying _____Staggering _____Falling
Walking and Turning _____Arms Raised for Balance _____Reaching for Support
_____Normal _____Stumbling _____Swaying _____Falling
Awareness _____Normal _____Confused _____Paranoid _____Sleepy or Stupor
_____Lack of Coordination
Odor _____Normal _____Alcohol _____Burned Rope
Appearance _____Red Eyes _____Vomiting _____ Half closed eyes
Reasonable Suspicion of current use, or impaired by _____Alcohol _____Drugs

Above behavior witnessed by

Signature __________________________________________ Date ________________________________
Signature (optional) __________________________________________  Date  ________________________________

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 twenty‐four
hours of 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.