Substance-Related Absence Report Form
Use this form to report an employee or student absence related to substance use or impairment concerns. Please provide clear and accurate information.
Full Name of Person Being Reported
*
First Name
Last Name
Role of Person Being Reported
*
Please Select
Employee
Student
Other
Department / Class / Group
*
Date of Absence or Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Substance or Impairment Concern
*
Please Select
Alcohol
Drugs (prescription or illicit)
Suspected Impairment (unknown substance)
Other
Brief Description of the Incident or Concern
*
Actions Taken (if any)
Full Name of Person Reporting
*
First Name
Last Name
Relationship to Person Being Reported
*
Please Select
Supervisor/Manager
Teacher/Faculty
Colleague/Classmate
Other
Contact Email for Follow-up
*
example@example.com
Submit Report
Should be Empty: