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476 EMPLOYEE INTERVIEW SHEET Employee Supervisor Name: Name: Date/Time Witness: Completed: Witness SUGGESTED QUESTIONS TO ASK WHEN REASONABLE SUSPICION EXISTS 1. Are you feeling ill? Yes No If yes, what are your symptoms? 2. Are you under a doctor's care? Yes No If yes, what are you being treated for? What is your doctor's name and address? When did you last visit your doctor? 3. Are you taking any medications? Yes No What medication? When did you take your last dosage? Do you have your prescription in your possession? Yes No 4. Do you have any pre - existing medical problems? Yes No Are you diabetic? Yes No Are you taking insulin? Yes No Do you have low blood sugar? Yes No Are you epileptic? Yes No 5. Do you have a cold? If yes, are you taking any: Yes No Pills/medications? Yes No Cough Medicine? Yes No Antihistamines? Yes No 6. Are you using any type of drug? Yes No If yes, what? 7. Did you drink alcohol or an alcoholic beverage today? Yes No If yes, what? How much? When did you start? When did you stop? With whom did you . drink? Employee Supervisor Signature: Signature: tess Witness ature: Signature: 79 Revised 01 -25 -05