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DISCIPLINARY ACTION NOTICE

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					DISCIPLINARY ACTION NOTICE Employee Receiving Discipline: __________________________________________________ Job Title: ________________________________Department:____________________________ Date of Notice: ___________________ It must be remembered that the employment relationship is based on mutual consent of the employee and the company. Accordingly, either you or the company can terminate the employment relationship at will at any time, for any or no reason. Further, the company can demote, transfer, suspend or otherwise discipline an employee in its sole and absolute discretion. 1. The employee is being disciplined for the following unacceptable performance and/or misconduct in the performance of his or her job duties. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

2. The following are any prior disciplinary discussions, notices or actions taken by the company towards the employee. Verbal [ ] Written [ ] Written with ___ days suspension without pay [ ] Other [ ] (Please describe):___________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ These previous discussions, notices or actions are referenced below by the date they took place; the type of action, such as verbal, written, written w/ suspension; and the performance deficiencies and/or misconduct discussed. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

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DISCIPLINARY ACTION NOTICE (Continued) 3. Description of the current facts or incidences, such as what is the job related problem or incident, when did it occur, where did it happen, related to the employee’s unacceptable level of performance or misconduct ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4. The employee is required to take the following actions to correct the performance deficiencies indicated in this notice and to meet the performance standards of the job. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Future incidences of misconduct or unacceptable performance may result in further disciplinary action to the employee, up to and including termination of employment. 5. Type of action this notice represents: Written [ ] Written With _____Day(s) Suspension without Pay [ ] Other [ ] Describe other: _____________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Supervisor’s signature: ___________________________________Date: __________________ Employee’s signature below signifies their receipt of a copy of this disciplinary action notice: Employee signature: _____________________________________Date:__________________ Copies to: Employee: Accepted [ ] Declined [ Employee’s Personnel File [ ] ] a copy 2/6/2001 2


				
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