Tmc Disciplinary Action Form Page 2
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1
2TMC
D
A
F
ISCIPLINARY
CTION
ORM
D. E
(
)
___________________________________________________
XPECTATION
S
OF TEAM MEMBER
_______________________________________________________________________________
□
□
□
’
:
TEAM MEMBER
S STATEMENT
AGREE
DISAGREE
NO COMMENT
:______________________________________________________________
ADDITIONAL COMMENTS
_______________________________________________________________________________
E. S
IGNATURES
“
(
)
I UNDERSTAND THAT I MUST COMPLY WITH THE TERMS AND CONDITIONS SET FORTH ABOVE IN THE
EXPECTATION
S
OF
”
TEAM MEMBER
SECTION AND THAT FAILURE TO COMPLY WITH THESE TERMS WILL SUBJECT ME TO FURTHER DISCIPLINARY
,
.
ACTION
UP TO AND INCLUDING TERMINATION OF MY EMPLOYMENT
MY SIGNATURE BELOW IS ACKNOWLEDGEMENT THAT I
.
HAVE RECEIVED A COPY OF THIS FORM
’
: _________________________________
D
: _______________
TEAM MEMBER
S SIGNATURE
ATE
’
: __________________________
D
: _______________
IMMEDIATE SUPERVISOR
S SIGNATURE
ATE
’
: _________________________________
D
: _______________
HR MANAGER
S SIGNATURE
ATE
(
): _________________________
D
: _______________
WITNESS SIGNATURE
IF APPLICABLE
ATE
F. A
S
PPROVAL
IGNATURES
A
: ____________________________________________
D
: _______________
PPROVAL
ATE
NEXT LEVEL SUPERVISOR
A
: ____________________________________________
D
: _______________
PPROVAL
ATE
/
REGIONAL ADMINISTRATOR
PROGRAM DIRECTOR
A
: ____________________________________________
D
: _______________
PPROVAL
ATE
DIRECTOR OF CHILDREN AND FAMILIES OR DESIGNEE
G. A
/
DDITIONAL SIGNATURES REQUIRED FOR SUSPENSIONS AND
OR TERMINATIONS
A
: ____________________________________________
D
: _______________
PPROVAL
ATE
V
P
H
R
ICE
RESIDENT OF
UMAN
ESOURCES
A
: ____________________________________________
D
: _______________
PPROVAL
ATE
V
P
O
ICE
RESIDENT OF
PERATIONS
A
: ____________________________________________
D
: _______________
PPROVAL
ATE
P
C
&
RESIDENT
EO
.
THIS FORM MUST HAVE ALL SUPPORTING DOCUMENTATION ATTACHED TO IT AS WELL AS ALL APPLICABLE SIGNATURES
Form Approved By: _____________________________________________________ Date:___________________________________________________________
003 Disciplinary Action Form
Page 2 of 2
Revised: 08/12
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