Name:_____________________________
Date:_______________________________
Department:_________________________
Reason for Disciplinary Action: (Check all that apply.)
___ Quality ___ Safety ____Conduct ___ Attendance
____ Insubordination ___ Housekeeping ___ Miscellaneous
You are receiving this disciplinary warning because of the following actions. (Describe in detail in behavioral terms.)
Unless this problem is corrected, further disciplinary action will be taken up to and including the termination of your employment. (Check the appropriate step in the progressive discipline policy.)
_____ Written Verbal Warning
_____ Written Warning
_____ 1-Day Suspension OR
_____ 3-Day Suspension OR
_____ 5-Day Suspension OR
_____ Employment Termination
Supervisor’s Signature: __________________________________
Date: _______________
I have received this disciplinary action and understand that unless this problem is corrected, further disciplinary action will be taken up to and including the termination of my employment.
Employee’s Signature: ___________________________________
Date: _______________
Human Resources Representative Signature: _________________
Date: _______________
Counseling Discussion Plan
Describe the behavior that caused the need for this disciplinary action.
Describe the outcome or result of this behavior. (How is productivity affected; work impacted; employees affected or inconvenienced; cost impacted as a result of the behavior, etc.)
Describe the desired behavior.
Employee Statement. (Describe any assistance needed to improve.)
