Form U - Report: Employee Suspected to have taken Alcohol

Name of employee : ____________________________________

Salary number : _____

Date : ______________

Time : ______________

Venue : ____________

Result of Breathalyser

Reading of breathalyser test:______________

Employee refused test : ___________________

No equipment available : __________________

Observations:

• Breath smells of liquor..............................Yes/No
• Bloodshot eyes.......................................Yes/No
• Unsteady on feet.....................................Yes/No
• Aggressive and refusal to co-operate.................Yes/No
• Bad co-ordination (ask person to touch his nose).....Yes/No
• Bad balance control (ask person to walk on a straight line and/or stand on one leg with his eyes closed)..........Yes/No
• In possession of alcohol.............................Yes/No
• Signs of vomiting....................................Yes/No

Name of person making the observation : ____________________________

Salary number : _____________

Designation : _______________

Signature : ________________________

Witness 1

I, ________________________________________________confirm the above observations.

Signature : _______________________

Witness 2

I, ________________________________________________confirm the above observations.

Signature : _______________________

Remarks by accused employee (voluntary)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________