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<br />DRAFT <br /> <br /> EMPLOYEE INTERVIEW SHEET <br />Employee Supervisor <br />Name: Name: <br />DatelTime Witness: <br />Completed: Witness <br />SUGGESTED QUESTIONS TO ASK WHEN REASONABLE SUSPICION EXISTS <br />1. Are you feeling ill? Yes No <br /> If yes, what are your symptoms? <br />2. Are you under a doctor's care? Yes No <br /> If yes, what are you being treated for? <br /> What is your doctor's name and address? <br /> When did you last visit your doctor? <br />3. Are you taking any medications? Yes No <br /> What medication? <br /> When did you take your last dosage? <br /> Do you have your prescription <br /> in your possession? Yes No <br />4. Do you have any pre-existing medical problems? Yes No <br /> Are you diabetic? Yes No <br /> Are you taking insulin? Yes No <br /> Do you have low blood sugar? Yes No <br /> Are you epileptic? Yes No <br />5. Do you have a cold? If yes, are you taking any: Yes No <br /> Pills/medications? Yes No <br /> Cough Medicine? Yes No <br /> Antihistamines? Yes No <br />6. Are you using any type of drug? Yes No <br /> If yes, what? <br />7. Did you drink alcohol or an alcoholic beverage today? Yes No <br /> If yes, what? <br /> How much? When did you start? <br /> When did you stop? With whom did YOU drink? <br />Employee Supervisor <br />Signature: Signature: <br />Witness Witness <br />Si2nature: Si2Dature: <br /> <br />78 <br /> <br />Rev. 10/27/04 <br />