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Indicate other unusual actions or statements, including when first observe <br />Were your observations made during, just preceding, or just after the <br />performing covered functions? Yes_ No <br />HISTORY <br />Number of Mondays missed or tardy in the last two months: <br />Has there been a recent change in the employee's level of performance? <br />Yes _ No Don't Know <br />SUPERVISOR' S OPINION <br />Indicate briefly what leads you to suspect drug and/or alcohol influence: <br />Indicate any additional substandard job performance: <br />Other Witnesses: <br />Date: <br />Supervisor's Signature <br />Date: <br />Supervisor - Witness' Signature <br />CONTACT THE HUMAN RESOURCES DIRECTOR AND FORWARD COMPLETED FORM TO HUMAN <br />RESOURCES <br />HR reviewed 4/20/2009 <br />24 <br />Attachment number 1 <br />F -5 Page 118 <br />