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Motor Skills: <br /> Lack of Coordination/Falling, Swaying, Staggering, Stumbling <br /> Unexplained Work-Related Accident or Injury Unsafe Actions <br /> Other: <br /> Were drugs or drug paraphernalia observed? Yes No <br /> Other observed actions or behavior(Specify): <br /> In my opinion, this behavior is interfering with the above-named employee's <br /> ability to perform his/her duties. <br /> Supervisor/Designee Signature Date/Time <br /> Witness Date/Time <br /> { <br /> Received by: Signature Date/Time <br /> 13 <br />