Employee Counseling Statement printable pdf download

Employee Counseling Statement

Employee Name_______________________________________

Date_______________

Reason for Conference

_____ Violation of Center Policy/Procedure

_____ Suspension Pending Investigation

_____ Sub-Standard Job Performance

_____ Other

What Policy(ies), Procedure(s), Standard(s) was not followed?

___________________________________________________________________________________

Details of the Incident/Allegation

What Specifically Occurred

___________________________________________________________________________________

When (Date and Time)

Date____/____/____

Time________________

Where (Location, Classroom, Area of Classroom)__________________________________________

How (What Lead to Incident)__________________________________________________________

Who Reported Incident (may omit for confidentially purposes)_______________________________

Were there witnesses (may omit names for confidentiality purposes) ___________________________

Investigation of Incident

Did the Employee admit violating policy/procedure/standard? _____ Yes _____ No

Were witnesses interviewed? _____ Yes

_____ No

Summary of Investigation:

___________________________________________________________________________________

Previous Counseling of Employee on Performance

_____Verbal

Date____/____/____

Concern Addressed_________________________

Employee Counseling Statement