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Record of Discipliary Action Form

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







Employee Record of Disciplinary Action



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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