Disciplinary Report Form
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1Disciplinary Report Form*
Employee Name:
Job Title:
Department:
Supervisor:
Date/Time of Occurrence:
Location:
Type of offense:
_____Absenteeism
_____Smoking in undesignated area
_____Tardiness
_____Posting items without permission
_____Leaving work area without permission
_____Fighting or creating conflict
_____Misuse of property/equipment
_____Using vulgar language
_____Leaking confidential information
_____Rudeness
_____Theft or fraud
_____Abusiveness
_____Lying or cheating
_____Bringing weapon onsire
_____Falsifying documents
_____Bringing illegal drugs/alcohol onsite
_____Unsafe behavior/horseplay
_____Failing to follow instructions
_____Poor work quality
_____Insubordination
_____Poor work quantity
_____Sleeping on the job
_____Poor hygiene
_____Disregarding dress code
_____Other
_____Other
Facts of Incident:
(Attach additional page if necessary)
Past Disciplinary Action:
Date
Type
Details
Written Report Prepared:
Yes
No
Yes
No
Yes
No
Consequence if incident occurs again:
Completed by:
Date:
Employee Statement regarding facts of incident:
(attach additional page if necessary)
Employee acknowledgement: My signature acknowledges that I have received this report and that it has been
discussed with me. I understand that my signature is not an admission of the incident or offense. I understand that
I may appeal this report by following instructions in Staff Handbook.
Date:
Employee Signature
Date
Witness Signature (if any)
*Complete immediately and forward within three (3) business days to: Director of Human Resources
HR form/9/2007
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