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OBSERVED BEHAVIOR--REASONABLE CAUSE RECORD <br /> <br />mployee: Name: .~ <br /> Identflr~ I~on Number. <br />baa rvatJotq: Date: r <br /> <br />lqrne: (from) am/pm to am/pm <br /> <br /> Loca~q: <br /> <br />1. Presence of Drugs and/or Drag ~e~ (~): <br /> <br /> ~~: ~D No~ <br />  ~ Dl~e~ <br /> <br />3. <br /> <br /> ia ~n~ <br /> <br /> Aw~: ~D No~e <br /> [~ O~er <br />4. MoOr S~ <br /> <br /> ~: ~D No~ <br /> [~ O~er <br /> <br /> W~ ~ ~ No~N <br /> Tumln~ [~ ~b~g <br /> ~D O~er <br /> <br />5. O~er Ob~w~ ~s or ~r (~): <br /> <br />(~) Cz)p) <br /> <br />m Flushed <br />1:3 Bloodshot Eyes <br />D Profuse Sweating <br />[] Runny Nose/Sore~ <br /> <br />[] Incoherent <br />[] Blowed <br />[] Blunt! <br /> <br />[] Confused <br />D Lack of Coordinalion <br />[] Mood Swings <br /> <br />[] Puncture Marks <br />1:3 Inappropr~te wearing of <br /> sunglasses <br />[] Tremora <br /> <br />[] Whispering <br />O Silent <br /> <br />[] Paranoid <br />[] Euphoria <br />[] Disoriented <br /> <br />n swaying <br />1:3 Failing <br /> <br />[] swaying <br />I'1 Failing <br /> <br />[] Stagge~lg <br /> <br />[] Reaching for Support <br /> <br />W'~nessed by: <br /> <br />(S~gnature) <br /> <br />(s~ature) <br /> <br />('lTde) (Date) (T~ne) <br /> <br />(T'l'de) (Date) (Time) <br /> <br />This document musl~ be prepared and signed by the wi'messes wil~in twenty-four (24) hours of the observed behavior <br /> or he,fo: re the results of lt~ tests are released, whichever is earlier (49 CFR 391.99(d)). <br /> l <br /> <br /> <br />