Disciplinary Action Form

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					Disciplinary Action Form
This Disciplinary Action Form can be used by a company as part of its employee
disciplinary procedure. Using this form creates a record of an employee’s unsatisfactory
performance or behavior and explains the potential consequences if the problem is not
corrected. Keeping records of employee discipline is essential for informing an
employee of performance problems and creating a trail of documentation for potential
legal action. This form is useful for small businesses when dealing with employees with
performance or behavioral issues.
                          DISCIPLINARY ACTION FORM

          _______________________ [Instructions: Insert the Company’s name]
         _______________________ [Instructions: Insert the Company’s address]
         _______________________ [Instructions: Insert the Company’s address]


Employee Name: _______________________ [Instructions: Insert the Employee’s name]

Employee Department: ___________________ [Instructions: Insert Employee’s department]

Date Action Taken: _______________________ [Instructions: Insert the date of the action]


Reason for Disciplinary Action:

___Quality ___Safety ___Conduct ___Attendance ___ Insubordination           ___ Other
[Instructions: Check all of the reasons for the discipline above]

Dear _____________________: [Instructions: Insert the Employee’s name]

You are receiving this disciplinary action because your behavior in regard to the documented
incident constitutes a failure to comply with ___________________ [Instructions: Insert the
Company’s name] personnel policies and acceptable business practices. By conducting
yourself in this way you have placed ___________________ [Instructions: Insert the
Company’s name] and your fellow employees in a detrimental position.

The specific behavior that has led to you receiving this disciplinary action is described as
follows:

Undesired behavior:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[Instructions: Describe the Employee’s undesired behavior]

Effect of undesired behavior on ___________________: [Instructions: Insert the Company’s
name]

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________



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______________________________________________________________________________
______________________________________________________________________________
[Instructions: Describe the effect the undesired behavior has on the Company]

What is expected from ___________________ [Instructions: Insert the Employee’s name] in
regard to behavior:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[Instructions: Describe what the expected Employee behavior would have been]

Disciplinary Action:

As a consequence of your behavior or conduct in regard to this discipline report,
___________________ [Instructions: Insert the Company’s name] has decided to make the
following actions:

_____ Reprimand
_____ Written Warning
_____ Suspension With Pay
_____ Suspension Without Pay
_____ Demotion – Loss of Duty
_____ Employment Termination
[Instructions: Check all of the disciplinary actions Company will take above]

Employee Comment:

Pursuant to ___________________ [Instructions: Insert the Company’s name] policy of
promoting fairness and employee input, you have the opportunity to provide your comment on
this disciplinary action.

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________




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EMPLOYEE:

I have received this disciplinary action and understand the disciplinary action taken. I also
underst
				
DOCUMENT INFO
Description: This Disciplinary Action Form can be used by a company as part of its employee disciplinary procedure. Using this form creates a record of an employee’s unsatisfactory performance or behavior and explains the potential consequences if the problem is not corrected. Keeping records of employee discipline is essential for informing an employee of performance problems and creating a trail of documentation for potential legal action. This form is useful for small businesses when dealing with employees with performance or behavioral issues.
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This document is also part of a package Human Resources: Termination & Disciplinary Action 19 Documents Included