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Doc NO:
LR 1
Revision:
1
Next Revision: Jan 2026
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Subject: Alcohol and Drugs Screening Form

Employee no: ________
Employee name: __________________________________
Date: ___ /______ /2026
Time: ___:___
Indicate which description fits the employee's behaviour best:
Breath:
Strong smell
Smell
No smell
Notes: ________________________________________________________________________
Face:
Sweating
Pale
Notes: ________________________________________________________________________
Pupils:
Wide
Small
Notes: ________________________________________________________________________
Speech:
Mumble
Slurred
Confused
Loud
Soft
Incoherent
Notes: ________________________________________________________________________
Stance:
Falling
Unsteady
Steady
Notes: ________________________________________________________________________
Conduct:
Talkative
Confused
Agressive
Frightened
Excited
Carefree
Notes: ________________________________________________________________________
General notes:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Signature of Assessor: _________________
Witness: _______________________
Date: ___/___/2026
Time:___:___