Employee Counseling Form

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Employee Counseling Form
Counseling Date: _____________________
Enter employee's full name
Employee’s Full Name:____________________________________________ Job Title: _________________________
Company Name
If applicable
Worksite Employer: __________________________________________ Location: _____________________________
Select all that apply
This Counseling is being issued because of the following:
 Attendance/Absenteeism
Misuse of Company Property
Violation of Lunch/Break Periods
Safety Violation
Violation of Time Clock Procedures
Behavior/Teamwork
Inappropriate Conduct
Sleeping on the Job
Violence in the Workplace
Inappropriate Dress
Substandard Work
_______________________
Other
(specify)
__________________________________
Insubordination
Tardiness/Punctuality
Incident Date: ___________________________________________ Time of Incident:____________________
Nature of Incident:
State what expectations he/she did not meet. Describe in detail what occurred, what is
unacceptable about the employee's work or actions, and any consequences. Note any past
communications with employee on this topic and earlier discipline.
Enter more than one if applicable
Witness(es) to Incident: ___________________________________________________________________________
Corrective Action:
State what employee is expected to do to correct the problem and what expectations he/she is to
meet. Indicate any actions you, the supervisor, will take in order to support the corrective action.
Employee Comments:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Please keep in mind that you are subject to further disciplinary action, up to and including termination of employment, if you fail to
make immediate and sustained improvement. Your employment remains at will, meaning that you or the Company may end your
employment at any time, with or without notice or cause.
I understand the above, although I may not agree. I have received a copy of this document that will be placed in my personnel file.
___________________________________ _____________
Employee’s Signature
Date
I decline to sign this Notice, but I know I am subject to further disciplinary action if I do not take the corrective action.
___________________________________ ____________
____________________________ ___________
Supervisor’s Signature
Date
Witness’s Signature
Date
11/2013

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