Record of Discipline Action Form
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Employee Name:
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Employee Title:
________________________________
Manager's Name:
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Manager's Title:
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Today's Date: ____/____/______
Incident Date: ____/____/______
Incident Time: ____:____
Incident Location:
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Description of Incident:
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Witnesses to the Incident:
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Names of those in attendance at the Disciplinary Action Meeting:
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The Disciplinary Action that will be carried out:
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If probation is given:
Start Date: ____/____/_____
End Date: ____/____/_____
Goals to Be Achieved Through this Disciplinary Action:
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________________________________
What will the consequences be for failure to improve the employee's performance or to correct their behavior?
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________________________________
________________________________
Were there any prior warnings on this subject, whether oral or written?
________________________________
________________________________
________________________________
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Employee Statement:
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________________________________
________________________________
________________________________
________________________________
________________________________
_______________________ Date_____
Signature of Employee
_______________________ Date_____
Signature of Supervisor
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