Record of Disciplinary Action
Employee Name Manager Name Today’s Date Incident Time Employee Title Manager Title Incident Date Incident Location
Description of the incident that occurred: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Witnesses to the incident (if applicable): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Names of those in attendance at current disciplinary action meeting: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Corrective or disciplinary action to be taken: Verbal Written Probation Suspension Other (explain below) ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (If on probation, period begins ___________________ and ends ___________________.) Goals to be Achieved: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Consequences for failure to improve performance or correct behavior: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Prior discussions or warnings on this subject, whether oral or written: ____________________________________________________________________________________ ____________________________________________________________________________________
Employee statement: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
I acknowledge that I have read and understand the above information and consequences.
_______________________________ Employee Signature _______________________________ Supervisor Signature
______________________ Date ______________________ Date
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