Positive Alcohol Test Record Form – Alcoblow Solutions Ltd

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 Used (Model & Serial No.): ________________________

• Method of Test: ☐ Contact (Mouthpiece / Paper Straw) ☐ Non-Contact (Screening)

• First Test Result (BAC): ________________________

• Confirmatory Test Result (BAC): ________________________

3. Circumstances Leading to Test

• Trigger:
  ☐ Pre-employment / Pre-access
  ☐ Random Testing
  ☐ Reasonable Suspicion
  ☐ Post-Incident / Accident
  ☐ Routine / Scheduled

• Observations / Behavior: __________________________________________
  (e.g., smell of alcohol, slurred speech, poor coordination, erratic behavior, involvement in incident, etc.)

4. Test Administration

• Tester Name & Position: __________________________________

• Witness Name & Position: __________________________________

• Tester Signature: ____________________ Date: ____________

• Witness Signature: __________________ Date: ____________

5. Employee Response

• Employee’s Statement / Explanation:

• Employee’s Signature: ________________________ Date: ______________

6. Management & HR Action

• Immediate Action Taken:
  ☐ Removed from duty
  ☐ Escorted safely home
  ☐ Medical assessment requested
  ☐ Disciplinary procedure initiated

• Follow-Up Action Required:
  ☐ Counseling / Rehabilitation referral
  ☐ Written warning
  ☐ Suspension
  ☐ Termination
  ☐ Other: _____________________________

• Supervisor / Manager Name: _____________________________

• Signature: ___________________________ Date: __________

7. Confidentiality & Filing

• Record filed by: _______________________________

• File Location: ☐ HR File ☐ SHE File ☐ Other: ____________

• Confidential handling confirmed: ☐ Yes

⚠️ Note: This form must be stored securely and accessed only by authorized personnel (HR, SHE, Legal).