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Disciplinary Action Form

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Disciplinary Action Form

Employee’s Name:

RIN #:

Department:

Job Title:

Performance/Behavior/

Attendance Infraction:

Date(s) of Infraction:

Details of Infraction (below):

Has this or a

___ Yes ___ No

(If yes, provide details previous disciplinary action below or attach documentation/previous disciplinary action form.)

similar infraction

occurred before?

Performance Improvement Plan including timeframe (below):

Recommended disciplinary action by Supervisor (below):

Recommended effective date of disciplinary action (below):

___ Verbal Counseling

___ Written Warning/Reprimand

___ Final Warning

___ Disciplinary Suspension

___ Discharge

Comments (below):

Signature of Supervisor:_________________________________________________________________

Date:__________________________

FOR HUMAN RESOURCES USE ONLY

Recommended disciplinary action approved?

___ Yes

___ No

Division of Human Resources Signature of Approval: __________________________________________

Date:_______________________

Please be advised that if you are involved in any further infraction of this nature, you may be subject to further disciplinary action up to and including

termination of employment. My signature indicates that I have received a copy of this disciplinary action form and understand the reason for this

corrective action. You may submit a written response to this disciplinary action. The response will be attached to this form. If you wish to file an appeal

of this disciplinary action, refer to Human Resources Policy # 900.2, Peer Review Appeal Process.

Signature of Employee: ____________________________________________________________________ Date: ______________________

Original form must be returned to the Division of Human Resources after the employee and supervisor have signed the form.

Please provide employee and immediate supervisor with a copy of the form signed by the Division of Human Resources

Revised July 2010

Disciplinary Action Form

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