WORKPLACE DRUG AND ALCOHOL INCIDENT REPORT
This report form is for incidents related to drug and alcohol use within [Your Company Name]. It's crucial to document such occurrences to ensure workplace safety and compliance with company policies.
Instructions:
Accuracy: Provide accurate and factual details in each section.
Confidentiality: This report is confidential and should be shared only with authorized personnel.
Response and Follow-up: Use this report to inform necessary response actions and preventative strategies.
Support: For assistance, contact [Your Company's Human Resources or Health and Safety Department].
Submit to: [Designated Department or Individual] at [Your Company Name]. This information will be used for immediate action and policy reinforcement.
Incident Details
Section | Details |
Date of Incident | [Month Day Year] |
Time of Incident | [HH:MM AM/PM] |
Location of Incident | [Workplace Location, e.g., Warehouse, Office] |
Type of Incident | [Drug Use, Alcohol Intoxication, etc.] |
Description of Incident | [Employee [Name] was found in an inebriated state during working hours in the warehouse area. A subsequent search revealed a hidden bottle of alcohol.] |
Persons Involved | [Name - Employee, John Doe - Witness] |
Witnesses | [Names of any witnesses, if applicable] |
Immediate Actions Taken
Section | Details |
Initial Response | [The employee was escorted to a safe area and HR was notified.] |
Medical Assistance | [Name] was evaluated by on-site medical staff for health concerns.] |
Incident Documentation | [Statements were taken from [Name] and witnesses.] |
Follow-Up Actions Recommended
Section | Details |
Disciplinary Action | [Consider appropriate disciplinary measures following company policy.] |
Policy Review and Reinforcement | [Reiterate company policies on drug and alcohol use to all employees.] |
Employee Assistance Program | [Offer support through an Employee Assistance Program (EAP) for substance abuse issues.] |
Report Submission:
Submitted To: ______________________[Name/Department]
Submission Date: ___________________[Month Day Year]
Signature of Reporting Individual: ____________________
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