Horry County Disciplinary Report Form November 2000 (Page 2 of 2) in pdf

SUPERVISOR’S STATEMENT: __________________________________________________________

_______________________________________________________________________________________

WITNESSES: __________________________________________________________________________

ACTION TO BE TAKEN:

______ Warning

______ Suspension

______ Dismissal

Consequences should incident occur again: ____________________________________________________________________

________________________________________________________________________________________________________

SUPERVISOR SIGNATURE: ____________________________________________________

EMPLOYEE’S STATEMENT: ____________________________________________________________

_______________________________________________________________________________________

MY SIGNATURE INDICATES ACKNOLWEDGEMENT OF RECEIPT, NOT AGREEMENT.

____________________________________

Employee Signature

ROUTING

Initials

Comments

Dept Head

_______

________________________________________________________________________

Division Director _______

________________________________________________________________________

_______

________________________________________________________________________

This report is to be made part of the official record of the above-mentioned employee and filed in the PIF.

Horry County Disciplinary Form 11/00

Horry County Disciplinary Report Form November 2000 Page 2