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COLORADO DEPARTMENT OF NATURAL RESOURCES stupor

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					                    COLORADO DEPARTMENT OF NATURAL RESOURCES

                OBSERVED BEHAVIOR/REASONABLE SUSPICION REPORT

Behavior that provides reasonable suspicion supporting a test for controlled substances or alcohol impairment must
be witnessed and documented by a supervisor. If at all possible, the behavior should be witnessed by two
supervisors. The witnesses should have received training in the detection of probable drug or alcohol use by
observing a person's behavior. The documentation of the employee's conduct shall be prepared by the witnesses
within 24 hours of the observed behavior or before the results of the tests are released, whichever is earlier.

Employee name: (print)                                                       SSN

Job title:

Behavior observed date:                                                      Time from              am/pm
                                                                             To:                    am/pm
Location Address:



                                        CAUSE FOR SUSPICION
                                          (Check all that apply)
                             Normal                                        Incoherent/confused
SPEECH                       Angry                                         Slurred
                             Whispering                                    Silent
                             Normal                                        Swaying
BALANCE
                             Staggering                                    Falling
                             Normal                                        Stumbling
WALKING
                             Swaying                                       Falling
                             Normal                                        Confused
                             Sleepy/Stupor                                 Paranoid
AWARENESS
                             Lack of Coordination                          Excessive yawning or fatigue
                             Slow movements                                Cannot control machinery/equipment
                             Red eyes                                      Dilated (large) pupils
                             Weight loss/malnutrition                      Dry mouth
APPEARANCE                   Unkempt appearance                            Flushed/pale face
                             Smell of alcohol                              Frequent sniffing
                             Sunglasses at inappropriate times             Profuse sweating
                             Specify the reasonable cause which indicates that drug usage may have been a factor in
                             the accident: (if applicable)
POST-ACCIDENT

                             Observed actions or behavior:
OTHER

Witnessed by:

 ____________________________________________________________________________________________
Name (print)                               Signature                    Date

_____________________________________________________________________________________________
Name (print)                               Signature                    Date


This document must be prepared and signed by the witnesses within 24 hours of the observed behavior or before the
results of the test are released, whichever is earlier (49 CFR 391.99(d)).
Rev. 3/96

				
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Description: COLORADO DEPARTMENT OF NATURAL RESOURCES stupor