Disciplinary Action form w Checklist

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					                                DISCIPLINARY REVIEW CHECKLIST

The purpose of this document is to remind supervisors of key steps/considerations in the disciplinary
process before a supervisor or manager recommends or takes disciplinary action.

The Supervisor or Manager must complete each question by placing a check mark on either the “YES” or
“NO” line.

                                                                                          YES        NO

    1.   Has the employee behaved/performed in a manner that does not comply
         with a Pathfinder rule, policy or standard?                                      _____      _____

    2.   Are the facts established by observation, documentation, or both?                _____      _____

    3.   Was the employee informed of the issues and given an opportunity to
         explain why discipline is not warranted?                                         _____      _____

    4.   Did you consider the factors for determining the severity of discipline?         _____      _____

    5.   To your knowledge, have similarly situated employees received similar
         discipline?                                                                      _____      _____

If the Supervisor or Manager answered “NO” to any of these questions and still wishes to discipline the
employee, the Director of Human Resources or Affirmative Action/Grievance Officer should be
contacted to discuss the matter.

In the case of termination, the Director of Human Resources or Affirmative Action/Grievance Officer
MUST be contacted to discuss the matter prior to issuing the termination.

____________________________________                                                ______________
Signature of Supervisor                                                             Date

NOTE: This form must be submitted to HR with a copy of the disciplinary action.
                                      Pathfinder Inc.
                                    Disciplinary Action Form

Employee Name:                                           Employee #

Department:                                              Date:

Action Taken:     90 day probationary Period           Verbal Counseling        Written Warning
   1 Written Warning       2nd Written Warning            Suspension # of days ( )       Termination

Problem Statement:

Corrective Action Required:

Time Frame:


The above has been discussed with me by my supervisor. I understand the contents and acknowledge
and understand the corrective action required. I also acknowledge and understand the potential
consequences of non-compliance. All grievances must be filed within five working days of termination.

______ _______                          __________
Employee Signature                                                      Date

___                             _________________                       _____           ______
Supervisor Signature                                                    Date

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