CONFIDENTIAL--IMPAIRED PERFORMANCE INCIDENT CHECKLIST

A supervisor should complete this form when an employee exhibits signs of possible impairment at work.

• Fill in appropriate observations and information below.
• Obtain a witness for your private interaction with the employee (if possible).
• Read the italicized statements below to the employee in as private a setting as possible.
• Have all those taking part sign this document if they are able to do so.
• Provide a copy of this document to the employee before he or she leaves the work site. If this is not possible, mail a copy to the employee as soon as possible.
• Make safe arrangements for the employee to leave the work site using the following guidelines.

Date and Time of Incident: __________________________ Location: _____________________________

Statement of Concern/Observations: "I wish to express my concern about your safety and well-being on-the-job. I have observed the following behaviors that lead me to believe you may be impaired in some way (Describe the observed behaviors)

(Description of behaviors or other indicators observed)

1._________________________________________________________________________________________

2._________________________________________________________________________________________

3._________________________________________________________________________________________

"Do you need medical assistance of any kind?" Yes ___ No ___ If yes, action taken:

__________________________________________________________________________________________

"I am placing you on Administrative Leave With Pay for the rest of the workday. For your safety and the safety of others, I want you to leave the work site as soon as possible. If you wish to contest my observations, you may request a medical evaluation from EOHS or from a medical facility of your choice. If the evaluation certifies you are impaired, you are responsible for the cost of the evaluation. If you choose to provide any medical reports, I will take them into consideration as I review your case. You may or may not face disciplinary action in the future, but you are not currently being disciplined.

"I want to make sure you have safe transportation to your home or to a medical facility. I strongly recommend that you do not drive yourself."

1. "Would you be willing to accept a taxicab ride paid for by UNM to your home or a medical facility?"
Yes __ No__. If yes, company called: ____________________________________. (The University has an account with the Yellow Cab Company identified as the "UNM Employee Safety Shuttle.")

2. "Is there a relative you can call to give you a ride?" Yes ___ No ___. If yes, name and phone number: ______________________________________________________________________________________

3. "Would you accept a courtesy ride from Campus Police" Yes ___ No ___. If yes, action taken: _______________________________________________________________________________________

"If you are planning to drive yourself, I must inform you that I am required to call the police. Will you consider one of the options we discussed above?"

Summary of arrangement made for transportation: _____________________________________________

___________________________________________________________________________________

Inform the employee of his or her responsibilities for returning to work:

1. "You are expected to return to work at the beginning of your next scheduled workday/shift. If you are unable to return, it is your responsibility to call in at that time and claim the appropriate leave. Paid administrative leave only covers the rest of this day."

2. "Before you will be allowed to return to work, you will need to provide EOHS with a letter from a licensed medical and/or mental health provider certifying that you are fit to return to work. EOHS (272-8043) can work with your health care provider to facilitate this process."

3. "Also be aware that you can contact the CARS program (Counseling Assistance and Referral Service 272-6868) for confidential counseling or referral if you desire."

4. "Finally, we will need to meet privately as soon as possible after you return to work."

Additional Information or Comments:

___________________________________________________________________________________________

___________________________________________________________________________________________

Employee Signature: ______________________________________________ Date: ________________
(This only certifies that I have received this form)

Employee Name (print)________________________________________________________________

Supervisor's Signature: ________________________________________________________________

Observer's Signature: __________________________________________________________

Comments may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm