INTOXICATION AND SUBSTANCE ABUSE CHECKLIST ACTIVITY

Scenario: Johnny is a Warehouse Operator and has been for the past
5 years. Over the past 2 months, hes been late 6 times and is on a
first written warning for tardiness. Johnny has never been written up
before to your knowledge, so you are worried about him. Johnny is
late to work again today so you are prepared to provide him with a
second written warning. Once Johnny shows up to work, you sit down
and start talking to Johnny about your concerns with his attendance
record. As soon as Johnny starts speaking, you notice a strong odor
coming from his mouth that smells something similar to alcohol. You
try to ignore the smell and focus on the conversation. As Johnny
continues to talk, you notice his eyes are glossy and he starts to
stumble over his words. He is not making much sense with stories and
you start to wonder why he is acting so different. You begin to
question Johnny and ask him to clarify what he is trying to say. Johnny
becomes irritable and starts arguing with you for no particular reason.
You try and calm Johnny down, but he doesnt seem to listen. Instead
he pushes the table back, and stumbles out of the office. He trips
over the lip on the door and almost falls. You realize, Johnny may be
under the influence of alcohol and/or drugs.
Using the scenario above, complete the Intoxication and Substance
Abuse Checklist with your partner. Please be prepared to explain why
or why not the situation below could be classified as a potential crisis
situation and what actions you would take next. Additionally, please
be prepared to demonstrate how you would hold a constructive
confrontation conversation with the associate regarding his behaviors.

INTOXICATION AND SUBSTANCE ABUSE CHECKLIST

ASSOCIATE INFORMATION
NAME

BUSINESS UNIT

CLOCK #

SHIFT

DATE

COST CENTER

OBSERVATIONS

Breath

(apparent odor of alcohol or substance abuse):

None

Strong

Faint

Moderate

Bad Breath

Burnt rope

Eyes:
Bloodshot
Normal

Glassy
Fixed Pupils

Glazed
Watery
Difficulty focusing
Dilated Pupils
Heavy Eyelids

Speech:
Confused
Stuttered
Thick Tongued
Accent
Lacks Continuity
Loud
Slurred
Mush Mouthed
Talkative
Incomprehensible
Garbled
Normal
Cotton Mouthed
Mixed or Rapid Subject Change
Other ________

Attitude / Personality / Appearance / Demeanor:

Excited
Combative
Hilarious
Indifferent
Talkative
Insulting
Care Free
Cocky
Fearful
Cooperative
Profane
Polite
Body Odor
Dizzy
Uncharacteristically Passive
Sleepy
Stuporous
Forgetful
Depressed
Distorted Sense of Time
Nervous
Runny Nose
Nose Bleeds
Anxious
Paranoid
Flat Affect
Panicky
Chills
Disoriented Excessive
Perspiration
Lethargic
Needle Marks
Mood Swings
Nauseous
Argumentative
Poor Control
Warm Skin
Distorted Sight
Distorted Hearing
Distorted Self Image
Flaccid Appearance
Unconsciousness
Frequent Lip Licking
Excessively Active
Still
Lack of Interest
Chronic Sinus/Nasal Problem
Lack of facial expression or animation
Other ________

Unusual Action(s):

Difficulty Sitting

Hiccuping
Belching
Vomiting
Fighting
Sobbing / Crying
Laughing
Rigidity
Absenteeism
Unexplained Accident(s)
Bizarre or Reckless Behavior
Other _______

Balance / Body Movement / Proprioception:

Hesitant
Stumbling

Swaying
Staggering Falling
Needs support
Other _________

Wobbling

Document any other unusual actions or statements :

Document physical evidence of intoxication / substance abuse (alcohol

beverage, drug paraphernalia, actual controlled or drug substance) :

Document signs or complaints of associate illness or injury :

Document any witness statements / observations :

Suspicious of:

Alcohol Intoxication

Substance Abuse

Effects of alcohol intoxication / substance abuse :

None
Extreme

Fit for Duty:

Yes

Suspected

Slight

Obvious

No

Is associate agreeable to undergo alcohol / drug testing?

Yes

No

Note: UNION FACILITIES ONLY

Supervisor must offer associate union representation if associate is
undergoing alcohol / drug testing and discipline may result. Please indicate if
associate accepted or declined representation below:
Accept

Decline

Additional Comments:

HR Specialist Name:
__________________________________________________________________

Supervisor: ______________________________

Witness(es):

______________________________

Signature: ______________________________
______________________________

Time:

______________________________

______________________________

Revised 5/2010