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Record of Discipliary Action Form

When discipline action must be carried out use the form below to document the situation.







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Employee Record of Disciplinary Action

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Record of Discipline Action Form


Employee Name: __________________________________

Employee Title: ___________________________________

Manager's Name: _________________________________

Manager's Title: _________________________________

Today's Date: ____/____/______

Incident Date: ____/____/______

Incident Time: ____:____

Incident Location:
____________________________________________________
Description of Incident:
____________________________________________________
Witnesses to the Incident:
____________________________________________________
Names of those in attendance at the Disciplinary Action Meeting:
____________________________________________________

The Disciplinary Action that will be carried out:
____________________________________________________

If probation is given:
Start Date: ____/____/_____

End Date: ____/____/_____

Goals to Be Achieved Through this Disciplinary Action:
____________________________________________________
____________________________________________________
____________________________________________________

What will the consequences be for failure to improve the employee's performance or to correct their behavior?
____________________________________________________
____________________________________________________
____________________________________________________

Were there any prior warnings on this subject, whether oral or written?
____________________________________________________
____________________________________________________
____________________________________________________

Employee Statement:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________


__________________________________ Date____________
Signature of Employee


__________________________________ Date____________
Signature of Supervisor











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