DHR REPRIMAND REVIEW FORM

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					                                                                                      Policy #1504
                                                                                    Attachment #1
                        DHR REPRIMAND REVIEW FORM
                                  (For Classified Employees Only)
  Employees are to refer to DHR Human Resource/Personnel Policy #1504 before completing this form.

Employee Name:                                                     SS#:

                                                     Division/Office/
Job Title:                                           Facility:

                                                                     Best time to reach you
Work Hours:                       Work Fax #:                        by phone:


Work Phone #:                                        Home Phone #:


Employee’s Preferred Mailing Address:
                                                            Street Name or P.O. Box


        City                         State                  Zip Code
******************************************************************************
Supervisor involved with issue(s):

Supervisor’s Phone #:                                         Fax #:

Human Resource/Personnel Representative:
Phone #:                                                      Fax #:

******************************************************************************
Supporting documentation related to the reprimand must be submitted with this form.
Copies of all documentation sent must be given to the supervisor who issued the reprimand
and your human resource/personnel representative. The documentation MUST include a
copy of the written reprimand or written confirmation of an oral reprimand.

******************************************************************************
If this is a request for reprimand review by more than one employee, complete the following:

Print Employee Name          Phone Number          Social Security #        Employee Signature




Form #1504-1                               Page 1 of 2                         Republished 11/19/03
               DHR REPRIMAND REVIEW FORM (continued)

Deliver, mail or fax this form, a copy of the reprimand and any supporting documents to:

                          Office of Human Resource Management
                                 Emploee Relations Section
                                        28th Floor
                                 Two Peachtree Street, NW
                               Atlanta, Georgia 30303-3142

                                   FAX #: 404/657-5802

For assistance, please call 404/656-5796
Monday - Friday, 8:00 a.m. - 5:00 p.m.




             Employee Signature                                           Date




Form #1504-1                               Page 2 of 2                 Republished 11/19/03