Blank Employee Disciplinary Action Form
Employee: Date of Warning:
Department: Supervisor:
TYPE OF VIOLATION: WARNING:
Attendance
Carelessness
Disobedience Violation Date:
Safety Tardiness Work Quality Violation Time: (a.m. / p.m.)
Other Place Violation Occurred:
Approved by:
Date
List All Previous Warnings (when warned and by whom):
Previous Warning: 1st Warning
Date
Verbal Employee Signature Date
Written
Previous Warning: 2nd Warning
Date Signature of person who prepared warning Date
Verbal
Written
Previous Warning: 3rd Warning Supervisor's Signature Date
Date
Verbal
Written
Employee HR Dept
EMPLOYEE DISCIPLINARY ACTION FORM
EMPLOYEE STATEMENT
EMPLOYER STATEMENT
Supervisor
WARNING DECISION
Name Title
COPY DISTRIBUTION
I have read this "warning decision". I understand it
and have received a copy of the same.
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