Guides & Toolkits

Responding to Suspected Impairment: Sample Tool

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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:

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