Employee Name	Employee Title
Manager Name	Manager Title
Today’s Date	Incident Date
Incident Time	Incident Location

Description of the incident that occurred:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Witnesses to the incident (if applicable):

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Names of those in attendance at current disciplinary action meeting:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Corrective or disciplinary action to be taken:

… Verbal   … Written     … Probation      … Suspension       … Other (explain below)

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(If on probation, period begins ___________________ and ends ___________________.)

Goals to be Achieved:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Consequences for failure to improve performance or correct behavior:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Prior discussions or warnings on this subject, whether oral or written: ____________________________________________________________________________________________________________________________________________________________________________________________________________

Employee statement:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I acknowledge that I have read and understand the above information and consequences.

 

_______________________________                                  ______________________

Employee Signature                                                                      Date

 

_______________________________                                  ______________________

Supervisor Signature                                                                     Date