West Virginia Drug- And Alcohol-Free Workplace Incident Report - Division Of Personnel Organization And Human Resource Development

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The Drug-Free Workplace
DRUG- AND ALCOHOL-FREE WORKPLACE
INCIDENT REPORT
(Please print)
Date of Incident: ___________ Name of Observer: _________________________
Relationship to Employee: ___Coworker
___Supervisor ___Manager
___Other (Explain) ________________________________
Employee’s Name: _________________________________________
Job Title: __________________________________
Department: ______________________________
Supervisor: ________________________________
Time Behavior Observed: ___________ ___AM ___PM
Location Where Behavior Observed: _______________________
Other Witnesses: ____________________________________________________
Behavior Reported To: ________________________
Observations:
1. Behavior:
________ Nervous
________ Sleepy
________ Confused
________ Excited
________ Fatigued
________ Poor memory
________ Insulting
________ Combative
________ Quarrelsome
________ Uncooperative
________ Overly talkative
________ Sweating
________ Exaggerated
________ Crying
________ Fighting
politeness
________ Slow
________ Tremors
________ Quick moving
reactions
2. Speech:
________ Slurred
________ Slow
________ Confused
________ Thick
________ Rambling
________ Pressured
West Virginia Division of Personnel
Incident Documentation
Organization and Human Resource Development

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