SAMPLE TOOL - RESPONDING TO SUSPECTED IMPAIRMENT FORM
Responding to Suspected Impairment
Employee Name: Date:
Supervisor Name:
Observer Name:
Incident or Concern Details
Action Note:
If there is concern employee may be or may become violent or threatening, or
may be in need of medical assistance, call security, police, or 911
Observations
Concerns regarding safety, health, or other work-related issues
Details from discussion with employee
Discussion of available services, if applicable
Safe arrangements (driven by/taxi, other work assigned, etc.)
Next steps / Return to work process
Notifications made to:
Signatures
Employee: Date:
Supervisor: Date:
Observer: Date:
