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CITY OF BATESVILLE <br /> 500 EAST MAIN <br /> BATESVILLE, ARKANSAS 72501 <br /> Phone 870-698-2400 <br /> Fax 870-698-2406 <br /> DRUG AND ALCOHOL TESTING <br /> REASONABLE SUSPICION VERIFICATION FORM <br /> Employee Name: <br /> Observation <br /> Date: Time (from am/pm to am/pm <br /> Location: \ <br /> Street City State Zip <br /> Behavior: (speech) <br /> Normal Incoherent Slurred Confused <br /> Slowed <br /> Other: <br /> (Awareness) <br /> Normal Confused/Disoriented Mood Swings <br /> Unusually Aggressive Behavior Drowsiness or Sleepiness <br /> Other: <br /> Appearance and/or Odors: <br /> Normal Disheveled/Unkept Dialated/Constricted'Pupils <br /> Dry Mouth Symptoms Puncture Marks Alcohol on Breath <br /> Flushed Bloodshot Eyes Profuse Sweating Tremors <br /> I Runny Nose/Sores Other <br /> 12 <br />