CORRECTIVE ACTION RECORD
The purpose of this document is to provide an accurate description of the event(s)/situation(s) that resulted in this corrective action. Provide as much
detail as possible and if necessary, attach additional documentation.
Indicate by check mark if:
First Written Warning: _________
Second Written Warning: _____________
Dates of Previous action(s): ______________________________________________________________________
Describe Current Incident (give all details including dates and times of events):
Describe the Correct Behavior or Action:
Plan of Action to Correct or Prevent Re-occurence:
Immediate, satisfactory improvement must be shown or further corrective action up to and including termination may be taken.
I have read and received a copy of this form:
Employee’s Signature: ____________________________________________________ Date:___________________________
Preparer’s Signature: ____________________________________________________ Date: __________________________
____________________________________________________ Date: __________________________
Distribution: 1 copy for the employee, 1 copy for the Department Head, and the Original to Human Resources