WRITTEN REPRIMAND RECORD
Employee Name: ID/Passport Number: Badge Number: Date of Reprimand:
Department/Craft: Position: Length of Service: Time in present position:
The following are brief statements employee's action(s) giving cause to this written
reprimand and suggested action(s) for avoiding any recurrences in the future.
What is the employee being reprimanded for?
(Give dates and details of specific incident(s)so that employee knows what behavior needs to be corrected.)
What policy/procedure or other conduct rule has been violated?
If conduct is repeated or other disciplinary problems develop, what additional action will likely result?
(Be specific, e.g. .put on probation, reprimand, termination, etc.)
Restate, for the employee's benefit, the expected performance standards which must be met in order to
correct the problem.
Has employee been warned for this action before? By whom? Date of warning
NO YES If YES, How? Written Verbal
Supervisor's Name/Title Supervisor's Signature and Date
Employee's Comments: (Employee may separate sheet if necessary).
Review by Manager (Review for consistent application Manager's Signature and Date
of discipline action)
Employee's Statement: My signature hereupon does not Employee's signature and Date
necessarily signify my agreement with the above, but attests that
I have read and understand the serious nature of this report.
Repetition of this action or other acts of similar nature may result
in a more serious corrective action and/or termination of my employment.
Review by HR Manager Signature and Date Witness (If required) Signature and Date