• Employee Disciplinary Action Form

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• Date*
• Employee Name Last, First*
• Employee Email*
• Employee Phone*

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• Department*
• Title/Position*
• Supervisor Name Last, First*
• Supervisor Email*
• Supervisor Phone*

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• Type of Violation* Select Attendance Absence Unexcused Conflict of Interest Harassment/Bullying Intoxicated at Work Late/Leaving Early Substandard Work Theft Threatening or Violent Behavior Violation of Safety Rules Willfull Damage of Company Property Other
• Date of Violation*
• Discipline Taken* Select Dismissal Suspension Warning - Verbal and/or Written
• Time Period for Improvement* Select 2 Weeks 30 Days 60 Days 90 Days
• Failure to Improve Will Result In:* Select Dismissal Suspension Reduction in Pay Demotion
• Supervisor Comments*
• Employee Comments*
• Was employee given copy of Company Handbook?*

  Yes
  No
  
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• Supervisor Signature and Date*
• Employee Signature and Date*