Form V - Report: Employee suspected to have taken Intoxicating (banned) Substances

Name of employee:_________________________________________

Salary number : ______

Date :________________

Time :________________

Venue : ________________________________

Result of urine test:

• Positive : ____________________
• Negative : ____________________
• Employee refuses : ____________
• No equipment available : ______

Observations:

• 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 intoxicating (banned) substances......Yes/No
• Slurred speech.........................................Yes/No
• Signs of vomiting......................................Yes/No
• Injection marks on skin................................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)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________