Positive Alcohol Test Record – Alcoblow Solutions Ltd Confidential: HR / SHE / Legal use only. Store securely per policy. Leave blank 1) Employee Information Full Name * Staff ID / Driver’s License No. * Department / Location * Job Title / Role * 2) Test Details Date of Test * Time of Test * Location of Test * Device Model * Device Serial No. * Method of Test * Contact (Mouthpiece / Paper Straw) Non-Contact (Screening) First Test Result (BAC) * Confirmatory Test Result (BAC) * Trigger * Select…Pre-employment / Pre-accessRandom TestingReasonable SuspicionPost-Incident / AccidentPeriodic / Scheduled Observations / Behavior * 3) Test Administration Tester Name & Position * Witness Name & Position 4) Employee Response Employee’s Statement / Explanation * 5) Management & HR Action Immediate Action Taken * Removed from duty Escorted safely home Medical assessment requested Disciplinary procedure initiated At least one option must be selected. Follow-Up Action Required Counseling / Rehabilitation referral Written warning Suspension Termination Other Supervisor / Manager Name * Remarks / Follow-up Notes 6) Confidentiality & Filing Record filed by * File Location * Select…HR FileSHE FileOther I confirm this record will be handled confidentially and stored securely per company policy. Submit Record Print
