Aurora University Department of Athletics
Drug Education, Counseling and Testing Program
Drug Testing Reasonable Suspicion Reporting Form
Appendix G
I,___________________________________,(staff name) under the reasonable suspicion clause that is outlined in the Aurora University Drug Education and Drug Testing Policy, report the following objective sign(s), symptom(s) or behavior(s) that I reasonably believe warrant ______________________________ (Student-Athlete) be referred to the Director of Athletics or his/her designee for possible drug testing. The following sign(s), symptoms(s) or behavior(s) were observed by me over the past _________hours and/or__________days.
Please check below all that apply:
The Student-Athlete has shown:
_____ irritability _____ physical outburst (e.g. throwing equipment)
_____ loss of temper _____ emotional outburst (e.g. crying)
_____ poor motivation _____ weight gain
_____ failure to follow directions _____ weight loss
_____ verbal outburst (e.g. to faculty, staff, _____ sloppy hygiene and/or appearance
teammates)
The Student-Athlete has been:
_____ late for practice _____ staying up too late
_____ late for class _____ missing appointments
_____ not attending class _____ missing/skipping meals
_____ receiving poor grades
The Student-Athlete has demonstrated the following:
_____ dilated pupils _____ over stimulated or “hyper”
_____ constricted pupils _____ excessive talking
_____ red eyes _____ withdrawn and/or less communicative
_____ smell of alcohol on the breath _____ periods of memory loss
_____ smell of marijuana _____ slurred speech
_____ staggering or difficulty walking _____ recurrent motor vehicle accidents and/or
_____ constantly running and/or red nose violations (provide dates____________)
_____ recurrent bouts with a cold or the flu _____ recurrent violations of Student Code of
(provide dates________________) Conduct policy
Other specific objective findings include:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Signatures:
__________________________________________
Name of Staff
__________________________________________ ________________________
Signature of Staff Date
Reviewed By:
__________________________________________ ________________________
Director of Athletics/Designee Date
__________________________________________ ________________________
Name of Counselor Consulted Date Consulted
Reasonable Suspicion Upheld
Reasonable Suspicion Denied
