Employee Discipline Notice
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1SSDHHC and WPSD
Employee Discipline Notice
Employee Name:
Supervisor Name:
Job Description:
Department:
Title:
Date of Notice:
Type of Problem:
Tardiness
Quality of Work
Carelessness
Absenteeism
Quantity of Work
Safety
Insubordination
Neatness
Intoxication or Drinking
Policy Breach
Language
Fighting
Other:
Incident Occurred on:
Date:
Verbal Warning
Time:
Written Warning
Place:
Suspension for _____ days
Discharge
Supervisor/Manager Explanation
1. Describe in detail what the employee has done.
2. Cite how this interferes with work environment, employee performance, business operations, or the well being of
other employees or your department.
3. Cite the specific rule, policy, law, standard, or regulation that was violated.
4. Explain in detail what the employee must do to improve performance or change behavior.
5. Cite the date that improvements are to be achieved.
6. Cite consequences if improvements are not achieved by date specified.
Note: Attach separate page if needed for more detailed explanations.
Employee Rebuttal:
Employee Signature:
Date:
Note: Signature acknowledges receipt only. It does not necessarily indicate agreement.
Supervisor’s Signature:
Date:
Dir. of Human Resources Signature:
Date:
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Parent category: Business