Preview Disciplinary Report Form

*Completeimmediatelyandforwardwithinthree(3)businessdaysto:DirectorofHumanResources

HRForm/12/2013



DisciplinaryReportForm*

EmployeeName: JobTitle:

Department: Supervisor:

Date/TimeofOccurrence: Location:

TypeofOffense:

Absenteeism   Tardiness  Leavingworkwithoutpermission

Misuseofproperty/equipment Theftorfraud  Leakingconfidentialinformation

Lyingorcheating   Falsifyingdocuments Unsafebehavior/horseplay

Poorworkquality   Poorworkquantity  Smokinginundesignatedarea

Poorhygiene   Postingitemswithoutpermission Fightingorcreatingconflict

Usinginappropriatelanguage  Rudeness  Abusiveness

Bringingweapononsite  Bringingillegaldrugs/alcoholonsite Failingtofollowinstructions

Sleepingonthejob   Disregardingdresscode  Other

FactsofIncident:(Attachadditionalpageifnecessary)_________________________________________________________

_______________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________



PastDisciplinaryAction:

Date________________Type_______________________Waswrittenreportprepared?Yes__No__

Details:_________________________________________________________________________________________

_______________________________________________________________________________________________



PastDisciplinaryAction:

Date________________Type_______________________Waswrittenreportprepared?Yes__No__

Details:_________________________________________________________________________________________

_______________________________________________________________________________________________



Consequenceifincidentoccursagain:_____________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Completedby:_______________________________________________Date:_________________________________

EmployeeStatementregardingfactsofincident:(attachadditionalpageifnecessary)________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Employeeacknowledgement:MysignatureacknowledgesthatIhavereceivedthisreportandthatithasbeendiscussedwithme.Iunderstand

thatmysignatureisnotanadmissionoftheincidentoroffense.Iunderstand

thatImayappealthisreportbyfollowinginstructionsintheStaff 

Handbook.

EmployeeSignature_________________________________________________Date:_____________________________________



WitnessSignature(ifany)_____________________________________________Date:_____________________________________

HTML Preview Disciplinary Report Form page number 1.