Employee Write Up Disciplinary Report Form

Disciplinary Report Form*
Employee Name: Job Title:
Department: Supervisor:
Date/Time of Occurrence: Location:
Type of offense:
_____Absenteeism _____Smoking in undesignated area
_____Tardiness _____Posting items without permission
_____Leaving work area without permission _____Fighting or creating conflict
_____Misuse of property/equipment _____Using vulgar language
_____Leaking confidential information _____Rudeness
_____Theft or fraud _____Abusiveness
_____Lying or cheating _____Bringing weapon onsire
_____Falsifying documents _____Bringing illegal drugs/alcohol onsite
_____Unsafe behavior/horseplay _____Failing to follow instructions
_____Poor work quality _____Insubordination
_____Poor work quantity _____Sleeping on the job
_____Poor hygiene _____Disregarding dress code
_____Other _____Other
Facts of Incident:(Attach additional page if necessary)
Past Disciplinary Action:
Date Type Details Written Report Prepared:
Yes No
Yes No
Yes No
Consequence if incident occurs again:
Completed by: Date:
Employee Statement regarding facts of incident:
(attach additional page if necessary)
Employee acknowledgement: My signature acknowledges that I have received this report and that it has been
discussed with me. I understand that my signature is not an admission of the incident or offense. I understand that
I may appeal this report by following instructions in Staff Handbook.
Employee Signature
Date:
Witness Signature (if any) Date
*Complete immediately and forward within three (3) business days to: Director of Human Resources
HR form/9/2007
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Employee Write Up Disciplinary Report Form PDF

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