HomeMy WebLinkAboutAgenda Packet - Finance & Human Resources Committee - 07/26/2016FINANCE AND POLICY COMMITTEE
July 26, 2016 - 3:30 PM
31111 Greenspot Road, Highland CA 92346
AGENDA
CALL TO ORDER
PLEDGE OF ALLEGIANCE
PUBLIC COMMENTS
NEW BUSINESS
1.Approve the June 28, 2016 Finance and Policy Standing Committee Meeting
Minutes
2.June 2016 Disbursements: Accounts payable disbursements for the period include
check numbers 247892 through 248104, bank drafts, and ACH Payments in the
amount of $3,046,838.12 and $320,467.84 for payroll.
3.Review the Drug and Alcohol Policy
ADJOURN
P LEASE NOT E:
P ursuant to Go vernment Co d e Sectio n 54954.2(a), any reques t fo r a d is ability-related modific ation or
ac commod ation, inc luding auxiliary aid s o r s ervices , that is s o ught in ord er to participate in the ab o ve-
agendized pub lic meeting s hould be d irected to the Dis tric t Clerk at (909) 885-4900 at leas t 72 ho urs prior
to said meeting.
Page 1 of 2
Minutes 6/28/2016 cmk
Subject to Approval
EAST VALLEY WATER DISTRICT June 28, 2016
FINANCE AND POLICY STANDING COMMITTEE MEETING
MINUTES
Ms. Koide called the meeting to order at 3:30 p.m. and Mr. Tompkins led the flag salute.
PRESENT: Directors: Morales, Smith
ABSENT: None
STAFF: Brian Tompkins, Chief Financial Officer; Kerrie Bryan, HR/Risk &
Safety Manager; Christi Koide, Administrative Assistant
GUEST(s): None
PUBLIC COMMENTS
Ms. Koide declared the public participation section of the meeting open at 3:31 p.m.
There being no written or verbal comments the public participation section of the
meeting was closed at 3:32 p.m.
APPROVE THE MARCH 29, 2016 FINANCE AND POLICY STANDING COMMITTEE
MEETING MINUTES
Directors Morales and Smith approved the March 29, 2016 Finance and Policy Standing
Committee Meeting minutes as submitted.
APPROVE THE APRIL 26, 2016 FINANCE AND POLICY STANDING COMMITTEE MEETING
MINUTES
Directors Morales and Smith approved the April 26, 2016 Finance and Policy Standing
Committee Meeting minutes as submitted.
MAY 2016 DISBURSEMENTS: ACCOUNTS PAYABLE DISBURSEMENTS FOR THE PERIOD
INCLUDE CHECK NUMBERS 247619 THROUGH 247891, BANK DRAFTS, AND ACH
PAYMENTS IN THE AMOUNT OF $4,884,566.29 AND $323,938.19 FOR PAYROLL.
Director Morales inquired about three disbursements made to the City of San
Bernardino. The Chief Financial Officer explained that these disbursements were
deposit reimbursements for accounts that were closed.
Page 2 of 2
Minutes 6/28/2016 cmk
FINANCIAL STATEMENTS FOR MAY 2016
The Chief Financial Officer discussed the decrease in water sales in May and that the
decrease could be a result of customers monitoring their sprinkler systems during
weather changes.
LIENS TO TAX ROLLS 2016-17
The Chief Financial Officer explained that delinquent water and sewer lien charges are
filed every year. Furthermore, although a property can be sold or transferred without
settling this debt, it is still the most efficient and effective method of collecting these
delinquencies.
AUDITOR COMMUNICATION LETTER IN CONFORMITY WITH STATEMENT ON AUDITING
STANDARDS (SAS) 114.
The Chief Financial Officer provided the committee with a brief overview of the
auditing standards and procedures for the annual financial audit.
ADJOURN
The meeting adjourned at 3:50 p.m.
James Morales, Jr., David E. Smith,
Governing Board Member Governing Board Member
STAFF REPORT
Agend a Item #2.
Meeting Date: July 26, 2016
Co nsent Item
To: F INANCE AND POLICY COMMITTEE Memb ers
From: General Manager/CEO
Subject: June 2016 Disbursements : Ac counts p ayab le dis b urs ements fo r the period includ e check numb ers
247892 thro ugh 248104, b ank drafts, and ACH Payments in the amount of $3,046,838.12 and
$320,467.84 for p ayro ll.
RECOMMENDATION:
Staff rec o mmend s that the Board of Directo rs review the District’s expense d is burs ements fo r the perio d June 1,
2016 through June 30, 2016 in the amount of $3,367,305.96.
BACKGROUND / ANALYSIS:
In the c o ntinued effort to be fisc ally trans p arent, the payment register fo r s upplies , materials , servic es , and
p ayro ll for June 2016 is attached fo r review and approval. This process p ro vid es the Board and the public an
o pportunity to review the exp ens es of the Dis tric t. Acc o unts P ayab le is p roc es s ed weekly, while payroll is
p roc es s ed b i-weekly. Information to justify eac h exp enditure is availab le thro ugh the Finance Dep artment.
Acc o unts payable d is b urs ements fo r the perio d inc lude c hec k numbers 247892 through 248104, bank drafts , and
ACH Payments in the amount o f $3,046,838.12 and $320,467.84 for payroll. Significant exp ens es greater than o r
equal to $50,000 are further explained b elo w:
AGENCY IDEALS AND ENDEAVORS:
Ideals and Endeavor II - Maintain An Enviro nment Committed To Elevated P ublic Servic e
(E) - Practice transparent & acc o untab le fis cal management
FISCAL IMPACT :
Suffic ient fund s have been b ud geted in the ad o p ted FY 2015-16 Budget.
Recommended by:
Jo hn Mura
General Manager/CEO
Res p ec tfully s ub mitted :
Brian To mpkins
Chief Financial Offic er
ATTACHMENTS:
Description Type
June 2 016 P ayment Register Backup Material
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/02/2016 247892 APPLIED MAINTENANCE SUPPLIES & SOLUTIONS LLC 559.72$
06/02/2016 247893 BOARD OF WATER COMMISSIONERS 7,316.00
06/02/2016 247894 BOARD OF WATER COMMISSIONERS 3,658.00
06/02/2016 247895 BRADEN HEYWOOD DBA GENESIS INDUSTRIAL SUPPLY 242.33
06/02/2016 247896 CHARLES P CROWLEY COMPANY, INC 878.24
06/02/2016 247897 CINTAS CORPORATION 309.61
06/02/2016 247898 CITY OF SAN BERNARDINO, PUBLIC WORKS DEPT 3,788.28
06/02/2016 247899 COLONIAL LIFE, PREMIUM 994.48
06/02/2016 247900 DAVID EARHART, EARHART PHOTOGRAPHY 117.45
06/02/2016 247901 EVENT FURNITURE SOURCE/ HIGH STREET INC. 2,033.90
06/02/2016 247902 EVERSOFT, INC 192.28
06/02/2016 247903 EXPERIAN 153.68
06/02/2016 247904 FLEET METAL BOX CORP 192.03
06/02/2016 247905 FRONTIER COMMUNICATIONS 52.08
06/02/2016 247906 GARY YOUNG 441.53
06/02/2016 247907 HATFIELD BUICK 94.15
06/02/2016 247908 HENRY SOWLE 451.46
06/02/2016 247909 HIGHLAND EQUIPMENT RENTAL 41.98
06/02/2016 247910 HUB CONSTRUCTION SPECIALTIES 178.61
06/02/2016 247911 INLAND WATER WORKS SUPPLY CO 4,373.33
06/02/2016 247912 K & L HARDWARE 18.33
06/02/2016 247913 LAMAR TRANSIT, LLC 900.00
06/02/2016 247914 MICHAEL REARDON 451.46
06/02/2016 247915 NAPA AUTO PARTS 263.44
06/02/2016 247916 RAGAN COMMUNICATIONS, INC 249.00
06/02/2016 247917
SAN BERNARDINO VALLEY MUNICIPAL WATER
DEPARTMENT 184,299.88
06/02/2016 247918 STAPLES BUSINESS ADVANTAGE 385.50
06/02/2016 247919 CELESTINE MCDONALD 150.00
06/02/2016 247920 DEBBIE WEBB 150.00
06/02/2016 247921 SILVERBAY PROPERTY CORP 61.15
06/02/2016 247922 BARBARA BRYANT 71.61
06/02/2016 247923 PHOENIX ENTERPRISES ILP1 52.06
06/02/2016 247924 KATHLEEN TUELL 115.00
06/02/2016 247925 ARTURO SOLANO 47.27
06/02/2016 247926 SHANNON SOSA 41.55
06/02/2016 247927 OLGA DIAZ 29.78
06/02/2016 247928 DISPOSAL CAL 37.36
06/02/2016 247929 KYLE MONZON 64.09
06/02/2016 247930 RUTH BICKING 2.10
06/02/2016 247931 BRIAN CAVAZOS 65.26
06/02/2016 247932 JENNIFER KIMBER 3.82
06/02/2016 247933 JOANNA SPAINHOWER 38.85
06/02/2016 247934 SANDRA GALINDO 57.79
06/08/2016 247935 KRISTIE ROHLEDER 2,500.00
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 1 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/08/2016 247936 ARTURO SOLANO 47.27
06/08/2016 247937 ALEXANDRA ROJAS 51.28
06/08/2016 247938 THR CALIFORNIA 111.23
06/08/2016 247939 RICHARD SALINAS 60.94
06/08/2016 247940 WASEEM BAJWA 22.05
06/08/2016 247941 SHARLEEN SALIM 54.08
06/09/2016 247942 APPLIED MAINTENANCE SUPPLIES & SOLUTIONS LLC 432.04
06/09/2016 247943 ASBCSD 50.00
06/09/2016 247944 BRINKS INCORPORATED 1,222.24
06/09/2016 247945 BURRTEC WASTE (GROUP) INDUSTRIES, INC. 573.47
06/09/2016 247946 CAL DISPOSAL 257.80
06/09/2016 247947 CALIFORNIA BANK & TRUST 151,805.32
06/09/2016 247948 COMPUTERIZED EMBROIDERY COMPANY, INC 270.93
06/09/2016 247949 COUNTY OF SAN BERNARDINO 1,350.00
06/09/2016 247950 CULLIGAN OF ONTARIO 50.00
06/09/2016 247951 DANICA HEADRICK 150.00
06/09/2016 247952 DELAFIELD CORPORATION 23.19
06/09/2016 247953 DENTAL HEALTH SERVICES 1,318.10
06/09/2016 247954 DIRECTV 236.97
06/09/2016 247955 HOSE-MAN, INC. 81.93
06/09/2016 247956 HUB CONSTRUCTION SPECIALTIES 179.39
06/09/2016 247957 INLAND WATER WORKS SUPPLY CO 1,158.64
06/09/2016 247958 JOCELYN HARRIS 150.00
06/09/2016 247959 K & L HARDWARE 6.47
06/09/2016 247960 NAPA AUTO PARTS 359.12
06/09/2016 247961 PACIFIC WESTERN BANK 2,199.26
06/09/2016 247962 PATTON'S SALES CORP 49.31
06/09/2016 247963 PC CONNECTION 4,650.00
06/09/2016 247964 POMONA VALLEY WORKSHOP 2,156.00
06/09/2016 247965 PRINCIPAL FINANCIAL GROUP 6,586.34
06/09/2016 247966 SAN BERNARDINO MUNICIPAL WATER DEPARTMENT 13,619.90
06/09/2016 247967 SAN BERNARDINO MUNICIPAL WATER DEPARTMENT 15,391.73
06/09/2016 247968 SOUTHERN CALIF OCCUPATIONAL HEALTH SERVICES 500.00
06/09/2016 247969 SOUTHERN CALIFORNIA EDISON COMPANY 26.56
06/09/2016 247970 STAPLES BUSINESS ADVANTAGE 699.47
06/09/2016 247971 TELEPACIFIC COMMUNICATIONS 2,812.23
06/09/2016 247972 THE GAS COMPANY 421.42
06/09/2016 247973 UNITED PARCEL SERVICE, INC. 21.75
06/09/2016 247974 VALERO MARKETING & SUPPLY COMP 10,297.62
06/09/2016 247975 VALLEY OFFICE EQUIPMENT 195.50
06/15/2016 247976 MINUTEMAN PRESS OF RANCHO CUCAMONGA 16,522.65
06/15/2016 247977 US POSTAL SERVICE 7,189.69
06/16/2016 247978 ARCELY ALANIS 78.15
06/16/2016 247979 LAURA HERNANDEZ 12.70
06/16/2016 247980 TAMMY ZELAYA 39.36
06/16/2016 247981 WEI GONG 26.76
06/16/2016 247982 BLANCA LOPEZ 65.81
06/16/2016 247983 MEHUJAEL LEPE 8.39
06/16/2016 247984 UNDERWOOD PARTNERS LLC 32.80
06/16/2016 247985 SOUTH WESTERN SEAL COATING 1,705.30
06/16/2016 247986 VERIZON 24.34
06/16/2016 247987 A JOHN WESLING 2,500.00
06/16/2016 247988 DANIEL CASTILLO 2,500.00
06/16/2016 247989 ALTERNATIVE HOSE INC 5.98
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 2 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/16/2016 247990 AUTO UPHOLSTERY INC. 154.12
06/16/2016 247991 CAVANAUGH & ASSOCIATES, PA 4,580.00
06/16/2016 247992 CHAMBER DIRECTORY SERVICES DEPT, 129.00
06/16/2016 247993 CHEM-TECH INTERNATIONAL INC 3,147.30
06/16/2016 247994 COUNTY OF SAN BDNO FLEET 115.20
06/16/2016 247995 CSR AIR CONDITIONING & HEATING 560.00
06/16/2016 247996 DANIELS TIRE SERVICE, INC 672.35
06/16/2016 247997 DOCUSIGN, INC. 12,012.15
06/16/2016 247998 DONEGAN TREE SERVICE 1,900.00
06/16/2016 247999 EYE MED VISION CARE 836.20
06/16/2016 248000 FRONTIER COMMUNICATIONS 635.23
06/16/2016 248001 HUB CONSTRUCTION SPECIALTIES 124.98
06/16/2016 248002 INLAND DESERT SECURITY & COMMUNICATIONS, INC 460.50
06/16/2016 248003 INLAND WATER WORKS SUPPLY CO 1,390.60
06/16/2016 248004 K & L HARDWARE 71.12
06/16/2016 248005 KONICA MINOLTA 1,186.07
06/16/2016 248006 KONICA MINOLTA BUSINESS 405.06
06/16/2016 248007 LORRAINE VOLPONE 1,500.00
06/16/2016 248008 MORGAN COMPANY/ WRM, INC. 1,664.36
06/16/2016 248009 NAPA AUTO PARTS 45.79
06/16/2016 248010 POMONA VALLEY WORKSHOP 924.00
06/16/2016 248011 PRO HOME CARE, JNS777 INC. 1,350.00
06/16/2016 248012 SAMSARA NETWORKS, INC. 4,489.39
06/16/2016 248013 SOUTHERN CALIFORNIA EDISON COMPANY 110,633.31
06/16/2016 248014 STAPLES BUSINESS ADVANTAGE 204.75
06/16/2016 248015 STB LANDSCAPE ARCHITECTS, INC 2,000.00
06/16/2016 248016 U.S. BANCORP SERVICE CENTER 27,109.27
06/23/2016 248020 SULEICA LOPEZ 56.95
06/23/2016 248021 SUSAN HEISLER 13.65
06/23/2016 248022 STEPHANIE BOWLES 4.04
06/23/2016 248023 EL SOL NEIGHBORHOOD EDUCATIONAL CENTER 48.04
06/23/2016 248024 TOM AFFATATI 57.53
06/23/2016 248025 RAUL PAIRO 65.78
06/23/2016 248026 ANGELINA ZELAYA 19.15
06/23/2016 248027 VERONICA PEREZ 23.95
06/23/2016 248028 LARRY RIVERA 58.79
06/23/2016 248029 MICHAEL VANNESS 32.27
06/23/2016 248030 HECTOR VARGAS 34.38
06/23/2016 248031 E & A BUSINESS GROUP CORP 15.62
06/23/2016 248032 MARIE M HERRERA 35.80
06/23/2016 248033 JADELL FOUTZ 24.67
06/23/2016 248034 GLADYS SALVATIERRA 100.00
06/23/2016 248035 LINDA GARCIA 650.00
06/23/2016 248036 LYRA LAO 150.00
06/23/2016 248037 WENDY CRAIG 35.00
06/23/2016 248038 AT&T 50.60
06/23/2016 248039 CITY OF SAN BERNARDINO, PUBLIC WORKS DEPT 9,699.18
06/23/2016 248040 DALE BARLOW 250.00
06/23/2016 248041 DAMON RUSSELL 70.00
06/23/2016 248042 FAIRVIEW FORD SALES,INC 55.49
06/23/2016 248043 FRONTIER COMMUNICATIONS 607.95
06/23/2016 248044 GENERAL SECURITY SERVICES, INC. 111.00
06/23/2016 248045 GOVERNMENT FINANCE OFFICERS ASSOCIATION 160.00
06/23/2016 248046 HUB CONSTRUCTION SPECIALTIES 555.52
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 3 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/23/2016 248047 K & L HARDWARE 547.01
06/23/2016 248048 LAMAR TRANSIT, LLC 900.00
06/23/2016 248049 NORM TERRY 98.46
06/23/2016 248050 PACIFIC WESTERN BANK 549.28
06/23/2016 248051 PLUMBERS DEPOT INC. 707.98
06/23/2016 248052 SAN BERNARDINO MUNICIPAL WATER DEPARTMENT 579,525.75
06/23/2016 248053 STAPLES BUSINESS ADVANTAGE 412.06
06/27/2016 248054 LORRAINE VOLPONE 50.00
06/30/2016 248055 ANGELINA ZELAYA 62.00
06/30/2016 248056 JULIA WARD 106.76
06/30/2016 248057 SUSANNA KAPOOR 88.14
06/30/2016 248058 GRACE CHUANG 54.87
06/30/2016 248059 SOCORRO GALLEGOS 3.03
06/30/2016 248060 E TISHA TREADWAY 46.17
06/30/2016 248061 JOSE SALDATE 25.65
06/30/2016 248062 ROBERT ANTHONY VICUNA 108.64
06/30/2016 248063 DAVID ORTEGA 33.76
06/30/2016 248064 FREO CA LLC 101.29
06/30/2016 248065 RHONDA DUMAS 5.51
06/30/2016 248066 FRANK ZAZUETA 63.00
06/30/2016 248067 BRIAN GOMEZ 20.85
06/30/2016 248068 ANA RUIZ 14.02
06/30/2016 248069 INNOVATIVE MARKETING TECHNIQUES 43.88
06/30/2016 248070 EAST HIGHLANDS RANCH MHOA 308,500.00
06/30/2016 248071 LYNWOOD OWNERS ASSOCIATION 98,146.00
06/30/2016 248072 ANDREW MATA 1,667.00
06/30/2016 248073 ASBCSD 30.00
06/30/2016 248074 AT&T 613.61
06/30/2016 248075 AUTO ZONE 19.70
06/30/2016 248076 BURGESS MOVING & STORAGE 892.62
06/30/2016 248077 CITY OF SAN BERNARDINO, PUBLIC WORKS DEPT 1,142.40
06/30/2016 248078 COLONIAL LIFE, PREMIUM 994.48
06/30/2016 248079 COMPUTERIZED EMBROIDERY COMPANY, INC 327.73
06/30/2016 248080 CP CONSTRUCTION, INC. 71,700.00
06/30/2016 248081 CSR AIR CONDITIONING & HEATING 2,025.00
06/30/2016 248082 DAILY JOURNAL CORPORATION 308.00
06/30/2016 248083 DAVID EARHART, EARHART PHOTOGRAPHY 117.45
06/30/2016 248084 DIGITAL NETWORKS GROUP, INC. 102.52
06/30/2016 248085 EXPERIAN 154.16
06/30/2016 248086 FRONTIER COMMUNICATIONS 49.67
06/30/2016 248087 HARPER & ASSOCIATES ENGINEERING, INC 5,750.00
06/30/2016 248088 HATFIELD BUICK 53.98
06/30/2016 248089 HOPKINS TECHNICAL PRODUCTS INC 1,356.84
06/30/2016 248090 HUB CONSTRUCTION SPECIALTIES 925.00
06/30/2016 248091 INLAND WATER WORKS SUPPLY CO 268.38
06/30/2016 248092 INNOVYZE, INC 15,437.50
06/30/2016 248093 K & L HARDWARE 70.64
06/30/2016 248094 LIEBERT CASSIDY WHITMORE LCW 70.00
06/30/2016 248095 METROPOLITAN LIFE INS CO 162.12
06/30/2016 248096 MORTON SALT, INC. 2,943.80
06/30/2016 248097 NATIONAL NOTARY ASSOCIATION 285.00
06/30/2016 248098
NINYO & MOORE GEOTECHNICAL SCIENCES
CONSULTANTS 3,995.25
06/30/2016 248099 PHOENIX LIFE INSURANCE COMPANY 81.86
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 4 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/30/2016 248100 PLUMBERS DEPOT INC. 2,970.00
06/30/2016 248101 POMONA VALLEY WORKSHOP 2,310.00
06/30/2016 248102 ROSEMOUNT ANALYTICAL, INC 3,300.00
06/30/2016 248103 THE GAS COMPANY 15.78
06/30/2016 248104 TYLER TECHNOLGIES 440.00
BANK DRAFTS
06/01/2016 DFT0001469 CALPERS/ DEFERRED COMPENSATION 13,379.39$
06/01/2016 DFT0001470 CALPERS/ RETIREMENT 36,296.58
06/01/2016 DFT0001474 STATE DISBURSEMENT UNIT 3,248.97
06/01/2016 DFT0001477 CALPERS/ MEDICAL 71,748.37
06/01/2016 DFT0001500 VERIFONE INC 22.00
06/03/2016 DFT0001467 CA SDI Tax 2,008.63
06/03/2016 DFT0001471 Federal Payroll Tax 28,017.84
06/03/2016 DFT0001472 Medicare 6,608.14
06/03/2016 DFT0001473 Social Security 194.92
06/03/2016 DFT0001475 State Payroll Tax 9,032.92
06/03/2016 DFT0001484 MERCHANT BANKCD 6,356.58
06/06/2016 DFT0001483 AMEX DISCOUNT 317.80
06/10/2016 DFT0001485 CA SDI Tax 19.99
06/10/2016 DFT0001486 Federal Payroll Tax 299.75
06/10/2016 DFT0001487 Medicare 64.40
06/10/2016 DFT0001488 State Payroll Tax 73.12
06/10/2016 DFT0001494 FORTE, ACH DIRECT INC, ACH FEES 350.62
06/10/2016 DFT0001499 TRANSFIRST DISCOUNT 8,116.72
06/15/2016 DFT0001491 CALPERS/ DEFERRED COMPENSATION 13,450.48
06/15/2016 DFT0001492 CALPERS/ RETIREMENT 36,296.58
06/15/2016 DFT0001497 STATE DISBURSEMENT UNIT 3,248.97
06/17/2016 DFT0001490 CA SDI Tax 1,946.40
06/17/2016 DFT0001493 Federal Payroll Tax 28,252.53
06/17/2016 DFT0001495 Medicare 6,407.44
06/17/2016 DFT0001496 Social Security 975.38
06/17/2016 DFT0001498 State Payroll Tax 9,019.41
06/20/2016 DFT0001506 CBB 3,902.98
06/22/2016 DFT0001512 VERIFONE INC 22.00
06/24/2016 DFT0001513 VERIFONE INC 22.00
06/28/2016 DFT0001503 CALPERS, UAL PAYMENT 32,122.00
06/29/2016 DFT0001504 CALPERS/ DEFERRED COMPENSATION 13,295.03
06/29/2016 DFT0001505 CALPERS/ RETIREMENT 36,296.59
06/29/2016 DFT0001510 STATE DISBURSEMENT UNIT 3,248.97
ACH PAYMENTS
06/02/2016 10001409 CPC SYSTEMS, INC 330.00$
06/02/2016 10001410 CV STRATEGIES 4,744.52
06/02/2016 10001411 DAVID HERNANDEZ 258.78
06/02/2016 10001412 EZEQUIEL ELECTRIC, INC. 1,547.00
06/02/2016 10001413 FARMER BROS. CO 763.14
06/02/2016 10001414 FRED STAFFORD 567.78
06/02/2016 10001415 FSA Only/East Valley Water District 1,583.81
06/02/2016 10001417 G & K SERVICES, CO. 630.72
06/02/2016 10001418 GARY STURDIVAN 567.78
06/02/2016 10001419 GONZALEZ, QUINTANA & HUNTER, LLC 8,000.00
06/02/2016 10001420 GORDON GRANT 489.95
06/02/2016 10001421 INDUSTRIAL RUBBER & SUPPLY 120.70
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 5 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/02/2016 10001422 INFOSEND, INC 950.13
06/02/2016 10001423 JAMES BROWNING 650.00
06/02/2016 10001424 JANA FOX 458.71
06/02/2016 10001425 LANDS END INC 396.03
06/02/2016 10001426 MICHAEL HENDERSON 552.66
06/02/2016 10001427 MUSICK, PEELER & GARRETT LLP 44,911.60
06/02/2016 10001428 PSA PRINTING & MAILING SERVICES, INC 528.62
06/02/2016 10001429 REBECCA KASTEN 650.00
06/02/2016 10001430 SCHUBERT ENTERPRISES INC 4,671.36
06/02/2016 10001431 STEVEN FARRINGTON 650.00
06/02/2016 10001432 THOMAS P ORTON 377.23
06/02/2016 10001433 VISTA PAINTS 227.45
06/02/2016 10001434 VULCAN MATERIALS COMPANY 1,556.97
06/09/2016 10001435 ADS ENVIRONMENTAL SERVICES 1,500.00
06/09/2016 10001436 ARCADIS U.S., INC 4,835.50
06/09/2016 10001437 ASHOK K. DHINGRA 14,581.62
06/09/2016 10001438 CANNON CORPORATION 792.00
06/09/2016 10001439 CIHIGOYENETCHE, GROSSBERG & CLOUSE 52,728.00
06/09/2016 10001441 CORA CONSTRUCTORS, INC. 41,785.96
06/09/2016 10001442 CORELOGIC SOLUTIONS INC. 315.00
06/09/2016 10001443 COUNTY OF SAN BERNARDINO, RECORDER- CLERK 1,388.00
06/09/2016 10001444 EXCEL LANDSCAPE, ICN 12,200.00
06/09/2016 10001445 FERGUSON ENTERPRISES, INC. 31,021.55
06/09/2016 10001446 FILARSKY & WATT LLP 140.00
06/09/2016 10001447 G & K SERVICES, CO. 695.40
06/09/2016 10001448 HIGHLAND AREA CHAMBER 129.00
06/09/2016 10001449 JOHN WITHERS ASSOCIATES 6,000.00
06/09/2016 10001450 JOSE MILLAN 80.00
06/09/2016 10001451 KEN TAYLOR 152.81
06/09/2016 10001452 LAND ENGINEERING CONSULTANTS 36,020.05
06/09/2016 10001453 LINCOLN NATIONAL LIFE INS CO. 1,255.50
06/09/2016 10001454 LINCOLN NATIONAL LIFE INS CO. 755.43
06/09/2016 10001455 MANAGED HEALTH NETWORK 241.92
06/09/2016 10001456 MIKE J. ROQUET CONSTRUCTION INC 5,260.00
06/09/2016 10001457 PARSONS BRINCKERHOFF, INC 17,979.19
06/09/2016 10001458 POWERSTRIDE BATTERY CO. 199.67
06/09/2016 10001459 SAFETY COMPLIANCE COMPANY 400.00
06/09/2016 10001460 TIM VITRANO 145.95
06/09/2016 10001461 VISTA PAINTS 66.47
06/09/2016 10001462 VULCAN MATERIALS COMPANY 569.32
06/09/2016 10001463 WAXIE SANITARY SUPPLY 258.09
06/16/2016 10001464 ADVANCED TELEMETRY SYSTEMS INTERNATIONAL, INC. 430.00
06/16/2016 10001465 CALIFORNIA TOOL & WELDING SUPPLY 62.77
06/16/2016 10001466 CLIFF'S PEST CONTROL 426.00
06/16/2016 10001467 DELAFIELD CORPORATION 222.70
06/16/2016 10001468 ENVIRONMENTAL SCIENCE ASSOCIATES/ESA 219,160.21
06/16/2016 10001469 EZEQUIEL ELECTRIC, INC. 1,909.00
06/16/2016 10001470 FERGUSON ENTERPRISES, INC. 1,113.48
06/16/2016 10001471 FSA Only/East Valley Water District 1,583.81
06/16/2016 10001473 G & K SERVICES, CO. 590.82
06/16/2016 10001474 GERALD SIEVERS 81.00
06/16/2016 10001475 HAAKER EQUIPMENT COMPANY 102.76
06/16/2016 10001476 HIGHLAND AREA CHAMBER 125.00
06/16/2016 10001477 JOHN ROBERT HARGRAVES 2,000.00
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 6 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/16/2016 10001478 JOHNSON POWER SYSTEMS 1,435.90
06/16/2016 10001479 LANDS END INC 311.23
06/16/2016 10001480 LEE & RO, INC. 8,429.50
06/16/2016 10001481 LEGEND PUMP AND WELL 196.00
06/16/2016 10001482 LESLIE'S POOL SUPPLIES, INC. 95.37
06/16/2016 10001483 MERCEDES KING 282.74
06/16/2016 10001484 MERLIN JOHNSON CONSTRUCTION 17,200.00
06/16/2016 10001485 MIKE J. ROQUET CONSTRUCTION INC 23,335.85
06/16/2016 10001486 MILLER SPATIAL SERVICES, LLC 8,945.00
06/16/2016 10001487 NETWORK FLEET, INC 124.75
06/16/2016 10001488 P.A.D. PALM AUTO DETAIL 825.00
06/16/2016 10001489 PSA PRINTING & MAILING SERVICES, INC 726.20
06/16/2016 10001490 STUBBIES PROMOTIONS INC 777.32
06/16/2016 10001491 UNDERGROUND SERVICE ALERT 112.50
06/16/2016 10001492 USA BLUE BOOK 81.42
06/16/2016 10001493 VERIZON WIRELESS 3,544.02
06/16/2016 10001495 VISTA PAINTS 249.04
06/16/2016 10001496 VULCAN MATERIALS COMPANY 2,123.15
06/16/2016 10001497 WAXIE SANITARY SUPPLY 156.77
06/23/2016 10001498 AIRGAS, USA LLC 160.80
06/23/2016 10001499 AMS, ANELLE MANAGEMENT SERVICES 1,264.79
06/23/2016 10001500 ANTHONY'S IRRIGATION 23,340.00
06/23/2016 10001501 ASHOK K. DHINGRA 8,791.26
06/23/2016 10001502 CIHIGOYENETCHE, GROSSBERG & CLOUSE 24,133.30
06/23/2016 10001503 CLEARFLY COMMUNATIONS 1,375.63
06/23/2016 10001504 CLINICAL LAB OF S B 3,133.00
06/23/2016 10001505 CORA CONSTRUCTORS, INC. 10,436.37
06/23/2016 10001506 EUROFINS EATON ANALYTICAL, INC 350.00
06/23/2016 10001507 G & K SERVICES, CO. 576.12
06/23/2016 10001508 JOSE MILLAN 160.00
06/23/2016 10001509 LAND ENGINEERING CONSULTANTS 4,592.00
06/23/2016 10001510 MICHAEL BAFFA 168.00
06/23/2016 10001511 NADERA MILBES 500.00
06/23/2016 10001512 PARSONS BRINCKERHOFF, INC 1,671.50
06/23/2016 10001513 SUPER PENNY MARKET 500.00
06/23/2016 10001514 VULCAN MATERIALS COMPANY 48.31
06/30/2016 10001515 ADDICTION MEDICINE CONSULTANTS 49.50
06/30/2016 10001516 ADVANCED TELEMETRY SYSTEMS INTERNATIONAL, INC. 2,250.00
06/30/2016 10001517 BOOT BARN, INC 141.75
06/30/2016 10001518 DIMENSION DATA NORTH AMERICA 734.08
06/30/2016 10001519 EXCEL LANDSCAPE, ICN 12,200.00
06/30/2016 10001520 EZEQUIEL ELECTRIC, INC. 1,913.00
06/30/2016 10001521 FARMER BROS. CO 502.61
06/30/2016 10001522 FERGUSON ENTERPRISES, INC. 5,218.21
06/30/2016 10001523 FSA Only/East Valley Water District 1,583.81
06/30/2016 10001525 G & K SERVICES, CO. 576.12
06/30/2016 10001526 INFOSEND, INC 32,419.48
06/30/2016 10001527 JOSE MILLAN 2,080.00
06/30/2016 10001528 LEGEND PUMP AND WELL 82,386.00
06/30/2016 10001529 MICHAEL JARAMILLO 500.00
06/30/2016 10001530 MUSICK, PEELER & GARRETT LLP 53,879.80
06/30/2016 10001531 OFFICIAL PAYMENTS CORP. 32.65
06/30/2016 10001532 PARSONS BRINCKERHOFF, INC 16,240.23
06/30/2016 10001533 PLUS 1 PERFORMANCE 400.02
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 7 of 8
PAYMENT DATE NUMBER VENDOR NAME AMOUNT
06/30/2016 10001534 SAFETY COMPLIANCE COMPANY 200.00
06/30/2016 10001535 SCHUBERT ENTERPRISES INC 110.00
06/30/2016 10001536 SHRED-IT US JV LLC 100.76
06/30/2016 10001537 SPECIAL DISTRICT RISK MGMT 500.00
06/30/2016 10001538 THE WINNER INDUSTRIAL SUPPLY INC 2,635.45
06/30/2016 10001539 TROY ALARM, INC. 180.00
06/30/2016 10001540 VULCAN MATERIALS COMPANY 1,132.76
TOTAL 3,046,838.12$
PAYMENT REGISTER
JUNE 1, 2016 - JUNE 30, 2016 Page 8 of 8
STAFF REPORT
Agend a Item #3.
Meeting Date: July 26, 2016
Dis cus s io n Item
To: F INANCE AND POLICY COMMITTEE Memb ers
From: General Manager/CEO
Subject: Review the Drug and Alc oho l P olic y
RECOMMENDATION:
Staff rec o mmend s that the F inanc e and Policy S tanding Co mmittee review the revised Drug and Alcohol Policy.
BACKGROUND / ANALYSIS:
Over the pas t fo ur years s taff has b een revising and c reating new p o lic ies and p ro grams to es tablis h boundaries
for ac c ep table b ehavior and p ro vide guidelines for b es t p rac tic es in the wo rkp lace. The Drug & Alc o ho l Po licy
is a policy that was rec ently id entified for revis io n.
Currently the Dis trict’s Drug and Alc o hol Po licy is a s mall s ectio n inc lud ed in the P ers o nnel Rules. Revis io n is
need ed to es tab lis h a clearer and consistent p o lic y whic h will ens ure c o mplianc e with all lo cal, s tate, and fed eral
laws , help management deal with any related is s ues that may arise, and aid the Distric t in meeting its legal
respons ibilities to ens ure the health, s afety, and welfare of all emp loyees .
T his revis ed polic y es tab lis hes the rules and proc edures regarding the us e of drugs and /or alcoho l as it pertains
to employment and the p ro c ed ure to b e used to tes t fo r drug and /or alcohol use. This p o licy meets the needs o f
estab lis hing a c lear and cons is tent policy by inc lus io n o f the following:
Guid ance fo r emp lo yees on what they c an and c an’t do
Ramific ations fo r violatio ns of the p o licy
Guid ance fo r s upervisors and managers ab o ut the proc edures they s ho uld fo llow
Reas o nab le drug tes ting informatio n
Medic atio n reporting req uirements
Rehabilitatio n/sup p o rt info rmatio n
T his po licy als o inc ludes a Reas o nab le S us p icion Evaluation Form to be us ed b y sup ervis o rs who s uspec t an
employee may be und er the influence of d rugs and/o r alc o hol. The form enables s up ervis o rs to d o c ument the
incident observed o r facto rs whic h caused the s upervisor to reas o nably s us pect that the emp lo yee may b e und er
the influenc e. The form req uires the sup ervis o rs s ignature and names of any witnes s es who may have o b s erved
the b ehavior.
All emplo yees will receive a c o p y of the Drug & Alcoho l Polic y and s ign an acknowledgement o f receip t o f
p olic y form. New-hires will receive a c o p y of the po licy during their new-hire orientation.
Recommended by:
Jo hn Mura
General Manager/CEO
Res p ec tfully s ub mitted :
Kerrie Bryan
HR/Ris k and Safety Manager
AGENCY IDEALS AND ENDEAVORS:
Ideals and Endeavor II - Maintain An Enviro nment Committed To Elevated P ublic Servic e
(B) - P romote a positive organizational culture
REVIEW BY OTHERS:
T his agend a item has b een reviewed b y the s enior and exec utive management team and Steve Filars ky, Dis trict
Lab o r R elatio ns Co unsel.
FISCAL IMPACT :
T here is no fis c al imp ac t as s o c iated with this agenda item.
ATTACHMENTS:
Description Type
Drug & Alcohol Policy Backup Material
Reaso nable Suspicion Evaluation Form Backup Material
EAST VALLEY WATER DISTRICT
Administrative Policies & Programs
Policy Title: Drug & Alcohol Policy
Original Approval Date:
July 27, 2016
Last Revised:
Policy No: 3.6 Page
1 of 5
East Valley Water District is concerned about employees being impaired for the performance
of duty or under the influence of alcohol, drugs and/or controlled substances at work, and the
use of such substances in the work environment. The District’s position is that any measurable
amount of drugs or alcohol in an employee’s system while on District time is counter-productive
to the goals and vision of the District. The District is also concerned about the possession,
distribution, purchase and/or sale of illegal drugs and controlled substances in the workplace.
These activities may adversely affect work performance, efficiency, safety, and health. In
addition, they constitute a potential risk to the welfare and safety of others, risks of injury to
other persons, property loss or damage, and/or negative image for the District.
The District’s policy is designed to promote a drug-free workplace and to comply with
applicable state, federal and local laws. In recognition of the public service responsibilities
entrusted to District employees, and because drug and alcohol usage can hinder a person’s
ability to perform duties safely and effectively, the following policy has been implemented.
Purpose
The purpose of this policy is to establish the rules and procedures regarding the use of drugs
and/or alcohol as it pertains to employment and the procedures to be used to test for drug
and/or alcohol use (the District maintains a separate Drug & Alcohol Policy for employees with
commercial licenses who are regulated by the Department of Transportation).
The District provides reasonable accommodations as required by law to those employees whose
drug or alcohol problem classifies them as disabled. While the District will be supportive of
those who seek help voluntarily before they test positive, the District will be equally firm in
identifying and disciplining those whose substance abuse, even if enrolled in counseling or
rehabilitation programs, results in performance deficiencies, danger to the health and safety
of others and themselves, and/or violations of federal, state or District laws and/or policies.
Violation of Policy
All persons covered by this Policy should be aware that violations of the Policy may result in
discipline, up to and including termination.
Individuals Covered
This Policy applies to all District employees. The Policy will be included in the Administrative
Policies and Programs Manual and a copy will be distributed to all employees.
EAST VALLEY WATER DISTRICT
Administrative Policies & Programs
Policy Title: Drug & Alcohol Policy
Original Approval Date:
July 27, 2016
Last Revised:
Policy No: 3.6 Page
2 of 5
Confidentiality
Any information about an employee’s use of prescription or non-prescription medication, the
results of any reasonable suspicion drug and/or alcohol testing, and/or an employee’s past or
present participation in rehabilitation or treatment for substance abuse shall be considered
confidential personnel information. The information received in enforcing this Policy shall be
disclosed only as necessary for: disciplinary actions and appeals; interactive process meetings
and reasonable accommodation efforts; or resolving legal issues. Any reports or test results
generated pursuant to this Policy shall be maintained in a confidential file, accessible only by
those authorized to receive the information, and separate and distinct from the employee’s
personnel file.
Restriction on the Use of Alcohol
Employees may not use, be under the influence, or possess alcohol under any of the following
circumstances: while on District property during working hours, while performing their duties
(whether or not on District property), while driving a District vehicle, or at any time when use
of alcohol would impair, to any extent, the employee’s ability to perform his/her duties or to
operate any District equipment.
The only exception to this restriction is for after-hours social events, conferences, and/or
ceremonial events in which an employee may responsibly consume alcohol.
Prohibition Against the Use of Drugs
No employee shall possess, use, sell, transfer, manufacture, purchase or transport drugs or
attempt to do so or report to work with drugs in his or her system. No employee shall possess,
use, sell, transfer, manufacture, purchase or transport prescription drugs, or attempt to do so,
or report to work with prescription drugs in his or her system, unless the prescription drug has
been lawfully prescribed to the employee (if such a prescription alters an employee’s ability to
perform the essential functions of their position, such use must be reported to the appropriate
supervisor).
Criminal Drug Statute Convictions
To fulfill its obligations under the Federal Drug-Free Workplace Act of 1988, the District requires
any employee who is convicted of any criminal drug statute, for a violation occurring in or
outside of the workplace, to provide written notice of the conviction to the Department
Director no later than five (5) days after the conviction. The District is also required, and will
fulfill its obligations to educate employees on the harmful effects of using and abusing drugs
and/or alcohol.
EAST VALLEY WATER DISTRICT
Administrative Policies & Programs
Policy Title: Drug & Alcohol Policy
Original Approval Date:
July 27, 2016
Last Revised:
Policy No: 3.6 Page
3 of 5
Whenever the District has reason to believe that Federal, State or local drug laws are being
violated, the District may refer the matter to the appropriate law enforcement agencies for
investigation and possible criminal prosecution.
Medication Reporting Requirements
Employees shall, in the case of prescription drugs, ask the prescribing physician and/or in the
case of medication available over-the counter, to review product packaging, to determine
whether the use of a prescription drug or over-the counter medication may impair his/her
ability to perform his/her normal job duties or to safely operate District equipment. Any
employee taking any over-the counter medication or prescription marked “do not drive,” “do
not operate heavy equipment” or similarly labeled, shall inform the appropriate supervisor of
the use of the medication or drug prior to reporting for duty.
In the case of prescription drugs, the supervisor shall determine whether the employee may
work, full duty or light duty, based on the written opinion of the employee’s medical provider
that the use of the medication may impair the employee’s ability to perform specific duties.
The District reserves the right to send the employee to the District’s industrial clinic for further
review and opinion if deemed necessary for clarification. Notices or communications required
by this section shall be confidential and disclosed only to the supervisor and the other
employees specifically authorized to receive information pursuant to this Policy.
Indications for Alcohol and Drug Testing
Employees - The District may require an employee to submit to a drug and/or alcohol screen
test under the following circumstances:
1. Pre-Employment.
2. When a supervisor has reasonable suspicion to believe, based upon specific and
documented facts and observations that the employee may be under the influence of
drugs and/or alcohol.
3. When a supervisor has reasonable suspicion to believe, based upon specific and
documented facts and observations that the employee either possesses, uses, sells,
transfers, manufactures, purchases or illegally transports alcohol, drugs, and/or drug
related paraphernalia or attempts to do so.
4. Follow-up testing for employees who have returned to work following a positive test and
their participation in a drug and/or alcohol rehabilitation program.
5. When an on duty employee is contacted by a police officer who has reasonable suspicion
to believe the employee is under the influence of alcohol or drugs or employee has been
involved in an on-duty vehicle related incident and the officer suspects the employee is
under the influence of drugs and/or alcohol.
EAST VALLEY WATER DISTRICT
Administrative Policies & Programs
Policy Title: Drug & Alcohol Policy
Original Approval Date:
July 27, 2016
Last Revised:
Policy No: 3.6 Page
4 of 5
Positive Test or Refusal to Test- Employees who refuse to take a test after direction to do so,
or who test positive, will be subject to discipline up to and including termination. A refusal to
test is defined as any of the following:
1. Not providing the District a written consent to take the test
2. The employee does not supply enough quantity of laboratory required sample for alcohol
or drug testing without sufficient or valid medical explanation
3. Tampering with a specimen or collection process
4. Tardiness to reporting Collection Site after time allocated for applicant or employee to
report without valid explanation
Drug and Alcohol Testing
A. Administration
1. The Human Resources Manager or an assigned designee will be responsible for
overseeing implementation of this Policy and the testing procedures. The Human
Resources Manager will be responsible for reviewing all disciplinary actions resulting
from violations of this Policy to ensure that the action proposed or taken is consistent
with the District’s Policy.
2. Responsibilities
a. Communicate directly with a licensed physician regarding any drug and/or
alcohol tests
b. Oversee testing programs
c. Provide training to supervisors and employees
B. Procedures
1. Mandatory Reporting - Any employee who has reason to believe that another
employee may be in violation of this Policy shall immediately notify his or her
immediate supervisor. The supervisor should take whatever immediate action is
deemed prudent to ensure the safety of the public and employees. Should the
supervisor have reasonable suspicion to believe, based upon specific and
documented facts and observations, that the employee may be under the influence
of drugs and/or alcohol, the employee should be immediately removed from the
workplace and placed upon administrative leave with pay until such time as testing
results confirm or refute the presence of drugs and/or alcohol. The supervisor shall
use the Reasonable Suspicion Evaluation Form to assist in making this determination.
2. Collection, Integrity and Identification-
a. After the employee has been advised about the reason for the test by the
Human Resources Manager or assigned designee, the employee will be
properly identified and the collection site personnel will explain the
mechanics of the collection process.
EAST VALLEY WATER DISTRICT
Administrative Policies & Programs
Policy Title: Drug & Alcohol Policy
Original Approval Date:
July 27, 2016
Last Revised:
Policy No: 3.6 Page
5 of 5
b. Procedures for urine collection will allow for individual privacy unless there
is reason to believe the individual may alter or substitute the specimen to be
provided. Samples will be tested for temperature and subject to other
validation procedures as appropriate.
3. Chain of Custody
a. Procedures for the storage and transportation of test specimens shall
conform to the Mandatory Guidelines for Federal Workplace Drug Testing
Programs established by the Department of Health and Human Services as
amended from time to time.
b. The test laboratory shall maintain custody of the specimens.
4. Testing Methods
a. All non-DOT tests will be screened using a technique deemed appropriate by
the collection site. The District will test for cannabinoids (marijuana),
cocaine, amphetamines, opiates, barbiturates, benzodiazepines, and
phencyclidine (PCP) as well as alcohol.
5. Notification
a. Any employee who tests positive will be notified by the licensed physician or
the Human Resources Manager.
Rehabilitation
A. Voluntary Disclosure - Any employee with a drug and/or alcohol problem may voluntarily
disclose, prior to a positive test, the problem to the Department Head or Human
Resources Manager, who shall refer the employee to the Employee Assistance Program
(EAP). An employee requesting this assistance may, at the District’s discretion, be given
work restrictions or be placed on leave while receiving treatment and until the
employee is drug and/or alcohol free. An employee’s voluntary disclosure of a substance
or alcohol abuse problem will not terminate any investigation, criminal or
administrative, initiated prior to the disclosure. Each employee is responsible for
seeking assistance before the employee’s drug and/or alcohol problem leads to violation
of this policy, or before the employee is asked submit to a reasonable suspicion drug
and/or alcohol test.
B. Leave Time - Employees must use available sick accrual, vacation accrual, floating
holiday or request personal leave of absence without pay if time off from work is
necessary for any treatment or rehabilitation program. The costs of long-term
rehabilitation or treatment services, whether or not covered by the employee’s medical
plan, are the ultimate responsibility of the employee.
The Human Resources Department is responsible for policy interpretation, administration and
enforcement, and will ensure signed policy acknowledgement will be received by all employees.
East Valley Water District Employee Acknowledgment
I acknowledge that I have received and reviewed the Drug and Alcohol Policy.
Employee Name (Print) __________________________Date _____________________
Signature_______________________________________________________________
Drug and Alcohol Policy
Reasonable Suspicion Evaluation Form
Employee Name: ___________________________________________________________
Observation Date and Time: _________________________________________________
Location of Employee: ______________________________________________________
Location of Supervisor: ______________________________________________________
Others present during activities or observations: ________________________________
Incident observed which give cause for reasonable suspicion:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Factors that may be considered in combination with those listed in 1-6 below include:
takes needless risks, accident(s), disregard for safety of others, unusual/distinct
pattern of absenteeism/tardiness, and increased high/low periods of productivity,
lapses of concentration or judgment.
1. Presence of alcohol, alcohol container, drugs, and/or drug paraphernalia
(specify)
__________________________________________________________________
2. Appearance:
__Flushed
__Bloodshot/glassy eyes
__Dilated/constricted pupils
__Dry-mouth symptoms
__Puncture marks
__Tremors
__Runny nose/sores
__Inappropriate wearing of
sunglasses
__Disheveled
__Profuse sweating
__Smell of alcohol
__Other:
3. Behavior/Speech:
__Incoherent
__Confused
__Agitated
__Slurred
__Slowed
__Sleeping on the job
__Unconscious
__Hostile/confrontation
__Other:
4. Awareness:
__Confused
__Lethargic
__Lack of coordination
__Mood swings
__Paranoid
__Euphoric
__Disoriented
5. Motor Skills/Balance:
__Unsteady
__Staggering
__Swaying
__Stumbling
__Falling
__Reaching for support
__Arms raised for balance
__Other:
6. Other observed actions or behaviors:
____________________________________________________________________
____________________________________________________________________
Supervisors Comments:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Supervisor’s Name: _______________________________________ Date: ___________
Witness Name: ___________________________________________ Date: ___________
Signature: _______________________________________________ Date: ___________