What this is
What is an impairment concern record?
What is an impairment concern record?
It is a structured account of an observed concern that a worker may be unable to work safely, written by the supervisor who witnessed it. It separates the immediate safety response (removal from safety-sensitive work) from the later, private determination of cause, and it is built against site substance policy and human rights legislation.
What triggers an impairment concern record?
Any observed indicator of possible impairment during safety-sensitive work: unsteadiness, slurred speech, confusion, unusual behaviour, smell of alcohol, drowsiness, or a sudden performance change. The trigger is what was seen, not a conclusion about substances.
How is an impairment concern record different from a fitness for duty assessment?
This record captures a single observed incident and the immediate response to it. A fitness for duty assessment is the separate, forward-looking determination of whether the worker can return to their role, usually informed by this record but conducted by occupational health.
Scope
When is an impairment concern record required?
This record captures one observed impairment concern and the immediate safety response to it. It is not the vehicle for fitness determinations, role classification, or ongoing wellbeing monitoring, each of which has its own template.
Use this template when
- A supervisor has just observed behaviour consistent with possible impairment during or before safety-sensitive work
- The worker has been removed, or needs to be removed, from safety-sensitive duties while the situation is assessed
- A new concern needs its own ID in the form IMP-2026-000, distinct from any prior concern involving the same worker
- The event needs a factual, timestamped record before memory of it degrades or the account gets contested
- A linked record depends on this one existing, most often a support referral or a workload review
Do not use it for
- Fitness for Duty Assessment, which determines whether a worker is currently able to perform their role safely, separate from any single incident.
- Safety Sensitive Role Register, which lists which roles carry additional fitness requirements, not individual concerns.
- Support Referral Record, which tracks the referral itself once this record has triggered one.
- Workload Review, which is the right template when fatigue rather than substance use is the suspected driver.
- Anything outside KnowHealth, which belongs in the workspace that owns that process.
Compliance mapping
Which Substance policy requirements does this satisfy?
The template is built against internal substance policy and general human rights obligations rather than a numbered external standard, so the mapping below cites the provision at the level the source actually supports.
| Clause | Requirement | Where it lands |
|---|---|---|
| Site substance and alcohol policy — recognition and response procedure | Observed behaviour is described factually and the worker is removed from safety-sensitive work before cause is determined | Immediate action |
| Site substance and alcohol policy — testing provisions | Any testing applies only where policy provides for it, and consent is sought and recorded | Process |
| Human rights legislation — duty to accommodate | Substance dependence is treated as a health condition eligible for support and accommodation, not only discipline | Process |
| Human rights legislation — confidentiality of medical information | Clinical detail is held by occupational health only; management receives an outcome, not a diagnosis | Header |
| Site substance and alcohol policy — welfare provisions | Safe transport is arranged rather than letting a worker believed to be impaired drive themselves home | Immediate action |
| Site substance and alcohol policy — fatigue and contributing factors | Fatigue is considered as an alternative or contributing explanation, with a workload review triggered where relevant | Underlying factors |
| Human rights legislation — procedural fairness | The worker is given an opportunity to explain and offered a support person before any process step proceeds | Immediate action |
What it does not cover
- A description that states a conclusion rather than an observation, which pre-judges cause before occupational health or the worker has had input.
- Removal from safety-sensitive work recorded as delayed or not done, which leaves the immediate safety risk unmanaged regardless of what happens afterwards.
- No record that a medical cause was considered, which risks treating a stroke or hypoglycaemic episode as a disciplinary matter.
- Clinical detail entered outside occupational health's restricted access, which breaches the confidentiality the whole process depends on.
- A worker sent home without safe transport confirmed, which converts a workplace safety concern into a road safety liability the organisation now owns.
Global
Impairment Concern Record requirements by country
Impairment concerns sit at the intersection of workplace safety law, human rights or disability discrimination law, and privacy law, and the balance between those three shifts by jurisdiction.
Provincial human rights codes and Stewart v. Elk Valley Coal
Dependence is a recognised disability requiring accommodation, but dismissal has been upheld where a worker fails to disclose it under a clear prior policy.
The record needs to show accommodation was genuinely offered, not that dismissal was the path of least resistance.
Americans with Disabilities Act, and DOT testing rules where applicable
Current illegal drug use is excluded from ADA protection, but a worker in treatment for dependence generally retains it, and regulated safety-sensitive roles carry separate mandatory testing regimes.
Whether DOT-style rules apply changes what Testing Applies Under Policy should mean for that role.
Fair Work Act 2009 and state work health and safety legislation
Employers carry a positive duty to manage impairment risk, alongside general protections against adverse action for a health condition.
A stand-down triggered by this record needs the same procedural fairness the Act expects of any disciplinary process.
How to complete it
How to complete an impairment concern record, step by step
Filling in every field correctly still leaves four judgement calls that decide whether the record holds up later.
Read the Factual Description field back and ask whether every sentence describes something seen or heard. Any word that names a cause rather than a symptom belongs in a later, private assessment, not here.
"Yes" on Possible Medical Cause Considered should mean someone actually asked the question and, ideally, offered medical assistance. A box ticked without that conversation happening is worse than an honest "no".
If a support referral or fitness assessment was promised in this record, its reference number needs to exist and be traceable. A record that promises follow-up nobody can find is functionally the same as one that never mentioned it.
Access Restricted To Occupational Health being marked Yes means nothing if the manager was copied on an email describing the worker's condition. The judgement call is whether the stated control matches the actual information flow that day.
What auditors find
Most common impairment concern record findings
Recurring gaps in how this record gets completed, and the fix each one implies.
| Finding | Clause | What fixes it |
|---|---|---|
| Description written from memory, days after the event | Site substance and alcohol policy — recognition and response procedure | Require the record to be started the same shift, even if some fields follow later |
| Removal from safety-sensitive work marked complete with no time recorded | Site substance and alcohol policy — response procedure | Make Time Removed mandatory alongside the removal decision |
| Support person offer recorded as Yes with no name attached anywhere | Human rights legislation — procedural fairness | Add a field capturing who the support person was, or note none was available |
| Testing consent field left blank when testing clearly occurred | Site substance and alcohol policy — testing provisions | Make Consent Obtained If Tested required whenever testing applies |
| Workload Review ID blank after Workload Review Triggered is Yes | Site substance and alcohol policy — fatigue and contributing factors | Block closure until the linked review reference is entered |
| Manager signs but occupational health's second signature lags for weeks | Human rights legislation — confidentiality of medical information | Route the record to occupational health automatically once the manager signs |
Case in point
Case in point: the record that read like a verdict
A cold-store supervisor at a processing plant found a worker swaying near a conveyor and wrote "clearly drunk on shift, smelled of alcohol." The worker was stood down and referred to HR the same afternoon on the strength of that single sentence.
Two days later occupational health confirmed the worker was hypoglycaemic, a known condition the site had no record of because the form never asked about medical history at the point of observation. The record had to be rewritten from witness accounts, and the disciplinary action was withdrawn. The template's own Possible Medical Cause Considered field, left unanswered in the original entry, was exactly the step that would have caught it.
The template
The template, field by field
The form exactly as it installs. Every field, option, score and conditional rule is editable, and the links to other templates come with it.
5 sections
- Reference
- HLT-036
- Archetype
- Record
- Record ID
- IMP-2026-000
- Scoring
- Not scored
- Direction
- n/a
- Singleton
- No
- Basis
- Substance policy, human rights legislation
- Links
- Links Worker
- Tags
- Health, Fitness
- Sections
- 5
- Fields
- 48
- Follow up fields
- 3
- Repeating sections
- 0
- Links out
- 6
Header
16 fieldsRecord ID*
Auto sequence. Format IMP-2026-000.
The record's own ID. Other templates point at this value.
Status*
Drives who this goes to next.
- Planned2 pts
- In progress2 pts
- Complete3 pts
- Deferred0 pts
- Open0 pts
- Closed3 pts
- Overdue0 pts
Date and Time*
Completed By*
Site*
Site ID*
Format SITE-000.
Links to FDN-001 Site ID
Worker*
Person ID*
Format PER-0000.
Links to FDN-003 Person ID
Record Confidentiality
Clinical detail stays with occupational health. Management receives a fitness outcome and any restrictions, never a diagnosis. Restrict access to this template accordingly.
Clinical Detail Held Separately*
- Yes3 pts
- No0 pts
Access Restricted To Occupational Health*
- Yes3 pts
- Partly1 pt
- No0 pts
Worker Consent Obtained*
Consent to share the fitness outcome with the employer. Withdrawal is the worker's right.
- Yes3 pts
- No0 pts
Safety First, Judgement Later
The immediate concern is removing the person from safety critical work without confrontation. What caused it, and what happens next, are separate questions handled afterwards and privately.
Concern Raised By*
Time Concern Raised*
Safety Sensitive Work Involved*
- Yes2 pts
- No0 pts
- N/Aexcluded from denominator
Observation
6 fieldsObserved Behaviours*
Unsteady, slurred speech, confusion, unusual behaviour, smell of alcohol, drowsiness, or performance change.
Observed By More Than One Person*
- Yes3 pts
- No1 pt
Factual Description*
What was seen and heard. No conclusions about cause.
Possible Medical Cause Considered*
Hypoglycaemia, stroke and medication side effects present exactly like intoxication. Consider medical first.
- Yes3 pts
- No0 pts
Medical Assistance Offered*
- Yes3 pts
- No0 pts
First Aider Involved
Immediate action
6 fieldsRemoved From Safety Sensitive Work*
- Yes, immediately3 pts
- Delayed1 pt
- No0 pts
Time Removed*
Conducted Privately*
- Yes3 pts
- No0 pts
Worker Given Opportunity To Explain*
- Yes3 pts
- No0 pts
Support Person Offered*
- Yes3 pts
- No0 pts
Safe Transport Arranged*
Never let somebody you believe is impaired drive home. That liability follows you.
- Yes3 pts
- Not needed3 pts
- No0 pts
Process
9 fieldsTesting Applies Under Policy
Policy Followed*
- Yes3 pts
- Partly1 pt
- No0 pts
Consent Obtained If Tested
- Yes3 pts
- Refused1 pt
- Not sought0 pts
Occupational Health Referral Made*
- Not needed3 pts
- Yes2 pts
- Needed not made0 pts
Referral ID
Links to HLT-013 Referral ID
Support Referral Offered*
Substance dependence is a health condition. Offering support alongside any process is both fair and effective.
- Yes3 pts
- No0 pts
Support Referral ID
Links to HLT-026 Referral ID
Return To Work Conditions Defined
- Yes3 pts
- No0 pts
Fitness Assessment Required Before Return*
- Yes3 pts
- No0 pts
Underlying factors
11 fieldsFatigue A Contributing Factor*
- No3 pts
- Possibly1 pt
- Yes0 pts
Workload Review Triggered
- Not needed3 pts
- Yes1 pt
Workload Review ID
Links to HLT-024 Review ID
Action Required*
Raise the action record, then enter its reference here.
- No2 pts
- Yes0 pts
Priority
- High0 pts
- Medium1 pt
- Low3 pts
CAPA ID
Format CAPA-2026-00000.
Links to FDN-014 CAPA ID
Action Owner
Manager*
Signature*
Occupational Health*
Second Signature*
HLT-036 · record IDs look like IMP-2026-000 · Links Worker
Open in KnowellaRun it with agents
From a document you fill in to a programme that runs itself
The form captures one event well. Keeping the response consistent across every supervisor and every shift, and making sure the linked referral actually happens, is the harder problem.
Holds every impairment concern record against the worker's history, flags when a linked support referral or workload review is promised but never created, and keeps clinical detail routed only to occupational health.
Tracks how quickly a worker is removed from safety-sensitive duties once a concern is raised, and surfaces sites where removal is consistently delayed.
Watches for records missing the procedural fairness steps, an opportunity to explain, a support person offered, before they become the basis of a disciplinary decision.
Coordinates the crew across KnowHealth, KnowSafe and KnowComply, rolls open concerns into one view, and holds every write for your approval before it touches a record.
This template lives in KnowHealth — employee wellbeing. Exposure monitoring, health surveillance, case management and return to work.
Meet KnowHealth→Glossary
Impairment Concern Record definitions and key terms
- Impairment concern
- An observed indicator that a worker may be unable to work safely, raised before cause is known and before any disciplinary or medical conclusion is reached.
- Safety-sensitive work
- A role or task where impaired performance creates an immediate risk of serious harm, and the trigger for removal ahead of any investigation.
- Duty to accommodate
- A legal obligation, strongest in human rights case law, to adjust work arrangements for a worker with a disability or health condition, including substance dependence, short of undue hardship.
- Occupational health
- The function that holds clinical detail separately from management and reports only a fitness outcome and any restrictions, never a diagnosis.
- Support referral
- A linked record offering assistance for substance dependence or another health condition, run alongside rather than instead of any safety process.
FAQ
Frequently asked questions about impairment concern record
What is the impairment concern record template based on?+
It is built against site substance and alcohol policy together with general human rights obligations, principally the duty to accommodate and the prohibition of discrimination in employment. It is not scored as a risk assessment; the scoring drives completion and routing.
What sections does the impairment concern record contain?+
Five sections: Header, Observation, Immediate action, Process, and Underlying factors. Together they hold 48 fields, 35 of them required.
Who completes an impairment concern record?+
The supervisor who observes the concern raises it at the time. HR becomes involved once the immediate safety response is in place, and occupational health handles anything clinical from that point.
Does this record replace a fitness for duty assessment?+
No. This record captures a single observed incident and the immediate response. A fitness for duty assessment is a separate, later determination of whether the worker can return to their role.
What happens if the worker refuses testing?+
The template records that outcome explicitly rather than treating it as a blank. Whether refusal carries consequences depends on the site's substance policy and, in regulated safety-sensitive roles, on the applicable testing regime.
Can this template be changed?+
Yes. Every field, option, score, and conditional rule is editable, and the links to Worker, Support Referral, and Workload Review records carry over. Most teams install it as it is, run it for a cycle, then adjust.
Keep going
Related templates and programmes
Industries this is written for
Programmes this belongs to
Used together in Wellbeing and Mental Health
Wellbeing Survey
Asks workers about workload, support, stress and how they are coping
Psychosocial Risk Assessment
Assesses workplace factors that affect mental health, including demand, control, support and change
Workload Review
Reviews whether workload, hours and staffing are sustainable for a team
Wellbeing Program Plan
Sets out what wellbeing support is available and how people access it
Support Referral Record
Records that a worker was pointed towards support services, without recording why
Fitness for Duty Assessment
Assesses whether a worker is currently able to perform their role safely
Written and reviewed by
Siddarth Singh
Founder & Chief Executive Officer, Knowella
Certified Safety Professional and industrial and systems engineer with more than a decade inside food supply chain, freight and manufacturing operations. This page was written against the current text of the standards it cites, not against secondary summaries of them.
- Certified Safety Professional (CSP), Board of Certified Safety Professionals
- MBA, University of Chicago Booth School of Business
- MS and BS, The Ohio State University, Industrial and Systems Engineering
- Six Sigma Black Belt
Sources and last review. Reviewed 16 August 2026 against:
- Site substance and alcohol policy — recognition, response and testing provisions
- Human rights legislation — duty to accommodate and confidentiality of medical information
- Stewart v. Elk Valley Coal Corp., 2017 SCC 30
- Americans with Disabilities Act, 42 U.S.C. § 12114 — illegal drug use exclusion
This page is general guidance, not legal advice. Confirm requirements with your jurisdiction’s regulator.