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Indicate other unusual actions or statements, including when first observed: <br />Were your observations made during, just preceding, or just after the period of the workday that the employee was <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 />22 <br />Attachment number 1 <br />F -6 Page 133 <br />