Fillable Form 129-01-004 - Written Notice printable pdf download

Form 129-01-004 (Revised 08/14/12)

W r i t t e n N o t i c e

Section I

Employee’s Name _______________________________________________________ Agency ___________________________

Offense Date(s) _________________ Issued Date__________________

Inactive Date*____________

*Inactive date is the issued date:

• plus 2 years for a Group I,

Issued by: _____________________________________________________________________________

• plus 3 years for Group II, or

Print name

Title

Signature

• plus 4 years for Group III.

Section II - Offense

Type of Offense: Check one and include Offense Category (See Addendum for Written Notice Offense Codes/Categories)

 Group I _______________

 Group II ______________

 Group III _______________

Nature of Offense and Evidence: Briefly describe the offense and give an explanation of the evidence.

(Additional documentation may be attached.)

Documentation attached? Yes _____, # of pages _____;

No _____

_______________________________________________________________________________________________________

Section III – Disciplinary action taken in addition to issuing written notice

Suspension from________________ through _______________ Return to Work ________________ #Days Suspended **______

Date

Date/Time

Transfer or demotion (check below as appropriate)

**Note: FLSA exempt employees may be

suspended in whole days only.

Reduced Duties with _______% disciplinary pay reduction*** effective ________________

Date

Disciplinary Transfer – Same Pay Band with _____% disciplinary pay reduction*** effective ____________

Date

***Note: Salary reduction

Demotion to lower Pay Band with ______% disciplinary pay reduction*** effective _____________

of at least 5% is required.

Date

Also requires HR approval

New Role Title ________________New Position #_____________New Location____________________

Termination __________________________

Effective Date

Section IV – Circumstances considered

Describe any circumstances or background information used to mitigate (reduce) or to support the disciplinary action above.

(Additional documentation may be attached.) Documentation attached? Yes _____, # of pages _____

No _____

_______________________________________________________________________________________________________

Section V - Notice to employee

It is expected that the situation described above will be corrected immediately in accordance with the Standards of Conduct for employees and/or the performance

measures outlined in your Employee Work Profile. A Written Notice may be used in place of a Notice of Improvement Needed Form, and may affect your

overall performance rating. In the event that this situation is not corrected, or another offense occurs, you may be subject to further disciplinary action as outlined

in the Standards of Conduct Policy. If you wish to appeal this disciplinary action, you may do so under the provisions of the Employee Grievance Procedure

within 30 calendar days of your receipt of this Written Notice. For more information about the Employee Grievance Procedure contact the Department of Human

Resource Management’s Office of Employment Dispute Resolution (EDR) at (804) 786-7994, toll-free at 1-888-23-ADVICE (1-888-232-3842), by FAX at (804) 786-

1606, or by e-mail at edr@dhrm.virginia.gov.

Section VI – Employee’s signature

Employee Signature________________________________________________________________

Date___________________

Your signature only acknowledges receipt of the notice and notes the date of receipt. Your signature does not imply agreement or disagreement with the notice

itself. If you refuse to sign, someone in a supervisory position within the agency will be asked to initial the form indicating that you received a copy of the form and

date of receipt.

Employee refused to sign/unavailable to sign

Witness Initials __________

Date _______________

Employee receives original, department and HR receive copies