9.34 Fitness for Duty: Impaired Employee
UWHC Administrative Policy Print
January 1, 2015
Personnel (Hospital Administrative)
As an employer and major healthcare provider, University of Wisconsin Hospital and Clinics (UWHC) is dedicated to
providing a safe environment, as well as promoting the health and welfare of its patients, visitors and
employees. UWHC employees are expected to report for work cognitively and physically unimpaired in their ability
to perform their duties at all work times. When conditions of impairment exist that may affect the ability of the
employee to perform his/her job in a safe and productive manner, the employee will be required to undergo a
fitness-for-duty evaluation. The institution is obligated by accreditation requirements and state and federal laws
and regulations to maintain a drug-free workplace. See Hospital Administrative Policy 9.05-Drug Free Workplace.
Additionally, this policy provides guidance for situations when information exists to believe that an employee,
either at or outside of the workplace, is believed to present a danger to him/herself and/or others.
II. PERSONS AFFECTED
This policy applies to all UWHC Authority regular employees and to Graduate Medical Education trainees.
For convenience, all those subject to this policy will hereinafter collectively be referred to as "employee"
despite that, in some cases, no employment relationship exists.
Non-UWHC employees, various students-in-training, volunteers, and employees of vendors, contractors or
agencies doing business on UWHC property, who violate this policy will be removed from UWHC premises
and treated in accordance with the terms of the agreement covering that person's relationship with UWHC
and/or reported to the appropriate authority for specific action.
A. Employee Self-Assessment (legally obtained drugs)
1. An employee's use of legally obtained drugs, such as prescription medication, may adversely
affect job performance and can pose significant risk to the safety of the employee or others. The
use or being under the influence of any legally obtained drugs while at work, on or in UWHC
property or vehicles, or during working hours is prohibited if such use or influence may affect the
safety of the employee, other employees, patients or member(s) of the public.
2. It is the employee's responsibility to be aware of the potential impact of legally obtained
drugs. An employee who has reason to believe that use of a legal drug may impair the
employee's job performance (e.g., drowsiness caused by medication) must report such drug use
to the employee's manager (or individual in charge) or Employee Health Services (EHS). UWHC
may require the employee to undergo a fitness-for-duty evaluation or comply with other
appropriate measures determined by management. Information regarding the employee's use of
legally obtained drugs will be maintained as confidential medical information.
B. Manager Assessment (reasonable cause)
1. An employee will be subject to a fitness-for-duty evaluation when a manager or individual in
charge has reason to believe the employee has impaired judgment or lacks physical or mental
capacity to satisfactorily perform the regularly required job duties. This includes not only
impairment due to suspected drug or alcohol use, but also non-drug related impairments or
2. Whenever feasible, another manager should make an independent assessment based on
observations of the same factors. When making the assessment, the manager(s) should use the
Manager's Report of Reasonable Cause form, available on U-Connect.
3. The manager or individual in charge should look at the incident and combinations of behaviors.
The following list is not to be considered all-inclusive:
a. Physical Condition
i. Blank stares
ii. Bloodshot eyes
iii. Body odor
iv. Chronic runny nose
v. Constricted pupils
vi. Dilated pupils
viii. Excessive sweating
ix. Flushed skin
x. Irregular breathing
xi. Odor of alcoholic beverages
xii. Poor depth perception
xiii. Slurred speech
xvi. Watery eyes
b. Work performance
i. Argumentative/threatening behavior
ii. Chronic/excessive lateness/absence
iv. Dozes/nods off
v. Fails to meet deadlines
vii. Frequent accidents on or off the job
viii. High error rate
ix. Hyperactive/restless behavior
x. Leaves work station without notice
xi. Long or frequent breaks/meals
xii. Needs repeated instruction
xiii. Overreactions to criticism
xiv. Rapid/unpredictable mood swings
xv. Reckless/disregards procedures
xvi. Significant change in pace; job takes more time
xvii. Dramatic decline in work performance
i. Avoidance of others
ii. Change in personal hygiene/appearance
iii. Frequent complaints from co-workers
iv. Increased patient/customer complaints
v. Outbursts - tears or anger
vi. Pattern of absences (e.g., before and after weekend or days off, etc.)
C. Fitness-for-Duty Evaluation
1. An employee is required to report, when directed, to EHS (Monday through Friday from 7:00 a.m.
through 4:30 p.m.) or the Emergency Department (ED) at all other times when EHS is not open
for a fitness-for-duty evaluation, and will be accompanied by his/her immediate manager,
Nursing Coordinator or a management designee. This may occur when an employee reports for
duty, is required to return to work after having been removed in association with an
investigation, or in the course of the work shift. Whenever possible, the manager must consult
with an Employee and Labor Relations Consultant (ELRC) or Human Resources Consultant (HRC)
prior to arranging a fitness-for-duty evaluation. Managers may contact a Nursing Coordinator for
assistance when performing fitness-for-duty exams after 4:30 p.m. or on weekends.
2. For all fitness-for-duty evaluations, the manager should call EHS (263-7535)or the ED manager
or Care Team Leader in advance to arrange the evaluation. It is important that EHS or the ED is
notified before the employee presents.
3. The manager, Nursing Coordinator or management designee shall document on the "Manager's
Report of Reasonable Cause" form (Appendix A) or the written equivalent, their observations of
the employee as the reasons they believe the employee is unable to initiate or continue normal
work duties and has been referred for a fitness-for-duty evaluation. When an employee is
presented for a fitness-for-duty evaluation, EHS or the Emergency Department staff will conduct
the evaluation based on the information provided on the "Manager's Report of Reasonable Cause"
form with a copy of the form forwarded to the HRC/ELRC. EHS and UWHC will have access to any
assessment and test results conducted by the Emergency Department.
4. The employee will be asked to sign the "Authorization for Release of Medical Information" form
provided by EHS/Emergency Department. An employee who refuses to test or sign the
"Authorization for Release of Medical Information" form will be presumed to have tested positive
for a drug(s) and/or alcohol and/or to otherwise be unfit for duty at that time.
5. Any medical/drug supplies (i.e., syringe, vial, pills, etc.) or other suspicious material observed
near the employee must be gathered and secured by an UWHC Security Officer, and these
materials must be presented to EHS/Emergency Department for referral to the laboratory for
analysis. Suspicious material not needed for analysis, may be given to University of Wisconsin
(UW) Police (608/262-4524) as contraband and possible physical evidence.
6. The fitness-for-duty evaluation may include a drug and alcohol screen, medical examination, and,
as appropriate, additional assessments may be recommended by EHS. A Chain of Custody form
will be completed and signed by the employee, authorizing the release of the results to UWHC.
7. EHS will release the results of the evaluation to the employee. UWHC shall maintain all
communications regarding the results of any drug or alcohol test conducted under this policy as
confidential except as otherwise provided herein. Employees who have tested positive for drugs
or alcohol under this policy may have access to test records upon written request to EHS. The
pass or fail results of any drug or alcohol screening will be released by EHS to the applicable
HRC/ELRC who will then share the information with the employee's manager assuming the Chain
of Custody form has been completed and signed by the employee. Any additional information,
including non-drug related conditions or impairments, may be shared with the HRC/ELRC as
1. An employee referred for a fitness-for-duty evaluation, or an employee suspected of being under
the influence of drug or alcohol who refuses to consent to a fitness for duty evaluation, will be
placed on a paid administrative leave of absence pending investigation by the employee’s
manager or management designee in consultation with the HRC/ELRC. For represented
employees, the administrative leave may be without pay following the occurrence of a pre-
disciplinary investigation meeting. The employee will not return to work until after all test results
are available and reviewed by EHS and the employee is determined to be fit for duty.
2. If the results are negative and an employee returns to work, the employee will be reimbursed for
any part of an unpaid administrative leave of absence.
3. If the results are positive, it is the responsibility of the employee's manager and director in
consultation with the HRC/ELRC, to determine appropriate levels of disciplinary action.
4. The HRC/ELRC may notify the UW Police at 608/262-4524 if its investigation suggests that
criminal conduct has occurred. If a supervisor has information or belief that criminal conduct
requiring immediate police response or investigation has occurred, he/she should contact the UW
Police. The supervisor must notify the HRC/ELRC whenever such a police referral is
made. Criminal conduct includes the sale or use of controlled substances as well as diversion
and/or theft of controlled substances.
E. Transportation to Home
An employee who a manager or individual in charge has reason to believe may be under the influence of
alcohol or drugs or suffering other impairment may be unfit to operate a motor vehicle. Therefore, the
manager, Nursing Coordinator, or management designee will arrange for the employee's transportation
home by some means other than the employee operating his/her personal vehicle, or contact Security if
the employee refuses assistance. Any cab vouchers that are provided must be one designated for
employee, and not patient, use.
F. Employee Assistance Program
1. Employees who are suspected to be unfit to work due to use of drugs and/or alcohol will be
referred to the Employee Assistance Program (EAP). See Hospital Administrative Policy 9.15. The
EAP provider is Empathia, Inc. (branded as LifeMatters). Empathia/LifeMatters counselors can be
contacted 24x7 by calling 1-800-634-6433 or by visiting www.mylifematters.com (password
UWHC1). After an incident involving drugs and/or alcohol, the employee will meet with the
manager, the HRC/ERLC and the union representative (if applicable) and if it is determined that
the employee may return to work, he/she may do so under a written agreement that may
mandate regular appointments with EAP and random drug and alcohol screenings. The term of a
written agreement is normally one year. Violation of the terms of the agreement will be reported
to the employee's manager, and discharge may result.
2. In most instances, an employee's request for a leave of absence to obtain treatment for
substance abuse will be granted by UWHC, except the treatment will not delay a decision to
discipline and/or discharge an employee for policy or work rule violations. The terms of the
employee's absence for treatment will depend on the employee's sick leave balance and eligibility
for leave of absence, and will be determined in consultation with the HRC/ELRC.
3. Employees who are deemed unfit-for-duty for reasons other than drug or alcohol use will, when
appropriate, be referred to EHS for assessment. EHS and the HR/ELRC will then coordinate
referral to the employee’s personal provider or another provider for recommendations and/or
G. Required Reporting for Licensed Professionals
In the event a supervisor has information or belief that a professionally licensed employee has a problem
with alcohol and/or drug use that impairs the employee's ability to perform his/her professional duties, the
supervisor must notify his/her department director and the ranking licensed professional (i.e., CNO, CMO),
who will, if appropriate, report the impairment to the Wisconsin Department of Safety and Professional
Services and send a copy to the HRC/ELRC.
H. Graduate Medical Education Trainees
1. GME trainees believed to be unfit for duty will be referred to EHS for assessment. A referral to
EAP may also be utilized in drug/alcohol situations. If treatment is recommended by the EAP
provider or the GME trainee’s personal physician/provider, a monitoring contract (with random
drug/alcohol testing through EHS, if appropriate) may be implemented to ensure compliance with
2. Once the GME trainee is released to return to work by their personal physician/provider, an
additional or alternative independent medical evaluation may be required to ensure the individual
is safe to practice as a physician. UWHC shall select the physician/practitioner to perform this
evaluation and shall pay the costs of the evaluation. The GME trainee is required to comply with
this evaluation and any recommended treatment and must be determined safe to practice prior
to returning to work.
3. The GME trainee shall report to EHS on their first day back to work to be cleared.
4. If the GME trainee does not comply with the fitness for duty process or the recommended
treatment plan, then disciplinary action or termination may result.
IV. EMPLOYEES BELIEVED TO BE A DANGER TO THEMSELVES OR OTHERS
If a manager has reason or information to believe that an employee, either at or away from work, is suicidal or
otherwise in danger of harming him or herself and/or others shall take the following steps. The manager should
consult with an ELRC, if feasible; however, such contact should not delay any responsive action.
A. The manager shall contact the employee and provide the telephone number for EAP. The EAP provider is
Empathia, Inc.(LifeMatters) and counselors can be contacted 24x7 by calling 1-800-634-6433.
B. Additionally, the manager shall contact Empathia, Inc. (LifeMatters) and request that a counselor contact
the employee directly.
C. The manager shall contact the identified emergency contact for that employee and advise them of the
concern regarding the employee's or others' safety.
D. If it is believed that the employee or others are in imminent danger, the manager shall contact the UW
Police, if the employee is at work, or the police department local to the employee (if the employee is at
home) to report the concern.
This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made for the
purpose of inducing any person to become or remain an employee of UWHC, and should not be considered
"promises" or as granting "property" rights. UWHC may add to, subtract from and/or modify this Policy at any
time. Nothing contained in this Policy impairs the right of a non-represented employee or UWHC to terminate the
employment relationship at-will. For represented employees, who are not at-will employees, this policy does not
supersede, limit nor grant any rights beyond those provided by the applicable collective bargaining agreement.
Hospital Administrative Policy 9.04-Work Rules: UWHC Authority
Hospital Administrative Policy 9.05-Drug-Free Workplace
Hospital Administrative Policy 9.15-Employee Assistance Program
Hospital Administrative Policy 9.20-Fitness For Duty: New Employee Health Assessment
Hospital Administrative Policy 9.22-Fitness For Duty: Health Service Clearance to Return to Work/Continue Work
Drug-Free Workplace Act of 1988
Drug-Free Schools and Communities Act of 1989
Senior Management Sponsor: VP, Human Resources
Author: Director, Employee and Labor Relations, Manager, Employee Health Services
Approval Committee: Administrative Policy and Procedure Committee
President & CEO