IMPAIRMENT CHECKLIST
|
Employee's Appearance |
|
| ______ | sloppy |
| ______ | inappropriate clothing |
|
Mood |
|
| ______ | withdrawn |
| ______ | sad |
| ______ | mood swings, high and low |
| ______ | suspiciousness |
| ______ | extreme sensitivity |
| ______ | nervousness |
| ______ | frequent irritability with others |
| ______ | preoccupation with illness and death (morbidity) |
|
Actions |
|
| ______ | physically assaultive (or threatening) |
| ______ | unduly talkative |
| ______ | exaggerated self-importance |
| ______ | rigidity - inability to change plans with reasonable ease |
| ______ | making incoherent or irrelevant statements on the job |
| ______ | over compliance with any routine (making it a ritual) |
| ______ | frequent argumentativeness |
| ______ | frequent outbursts of crying |
| ______ | excessive amount of personal telephone time |
| Absenteeism | |
| ______ | multiple instances of improper reporting of time off |
| ______ | excessive sick leave |
| ______ | repeated absences following a pattern |
| ______ | excessive lateness in the morning, or upon returning from lunch |
| ______ | peculiar and increasingly improbable excuses for absences |
| ______ | high absenteeism rate for colds, flu, gastritis, general malaise, etc. |
| ______ | frequent unscheduled short-term absences (with or without medical explanation) |
| ______ | frequent use of unscheduled vacation time |
| "On The Job" Absenteeism | |
| ______ | continued absence from job location more than the job requires |
| ______ | frequent trips to water fountain or restroom |
| ______ | long coffee breaks |
|
Accidents |
|
| ______ | physical complaints on the job |
| ______ | accidents on the job |
| ______ | accidents off the job |
|
Work Patterns and Production |
|
| ______ | current work assignment requires more effort than previously taken |
| ______ | work takes more time to produce |
| ______ | difficulty in recalling instructions, understanding office procedures, etc. |
| ______ | display of disinterest in work |
| ______ |
increased difficulty in handling complex assignments |
| ______ | difficulty in recalling previous mistakes (although these have been brought to the employee's attention) |
| ______ | general absentmindedness, forgetfulness |
| ______ | alternate periods of high and low productivity |
| ______ | coming to work in an intoxicated condition |
| ______ | missed deadlines |
| ______ | mistakes due to poor judgement |
| ______ | outside complaints bout the employee's work |
| ______ | improbable excuses for these poor patterns |
| ______ | carelessness |
| Employee Relationships on the Job | |
| ______ | over-reaction to real or imagined criticism |
| ______ | wide swings in job morale |
| ______ | borrowing money from co-workers |
| ______ | unreasonable resentments against co-workers |
| ______ | repeated and compulsive criticism of the company |
| ______ | persistent requests for job transfer |
| ______ | unrealistic expectation for promotion |
| ______ | abrasiveness with others (managers and/or co-workers) |
|
Work Related Relationship in the Community |
|
| ______ | inappropriate behavior at company business meeting |
| ______ | complaints from the community concerning the employee |
Documentation Data
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Date
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Behavior/Incident
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Comments
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