HTML Preview Disciplinary Report Form page number 1.


*Completeimmediatelyandforwardwithinthree(3)businessdaysto:DirectorofHumanResources
HRForm/12/2013
DisciplinaryReportForm*
EmployeeName: JobTitle:
Department: Supervisor:
Date/TimeofOccurrence: Location:
TypeofOffense:
Absenteeism Tardiness Leavingworkwithoutpermission
Misuseofproperty/equipment Theftorfraud Leakingconfidentialinformation
Lyingorcheating Falsifyingdocuments Unsafebehavior/horseplay
Poorworkquality Poorworkquantity Smokinginundesignatedarea
Poorhygiene Postingitemswithoutpermission Fightingorcreatingconflict
Usinginappropriatelanguage Rudeness Abusiveness
Bringingweapononsite Bringingillegaldrugs/alcoholonsite Failingtofollowinstructions
Sleepingonthejob Disregardingdresscode Other
FactsofIncident:(Attachadditionalpageifnecessary)_________________________________________________________
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PastDisciplinaryAction:
Date________________Type_______________________Waswrittenreportprepared?Yes__No__
Details:_________________________________________________________________________________________
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PastDisciplinaryAction:
Date________________Type_______________________Waswrittenreportprepared?Yes__No__
Details:_________________________________________________________________________________________
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Consequenceifincidentoccursagain:_____________________________________________________________________
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Completedby:_______________________________________________Date:_________________________________
EmployeeStatementregardingfactsofincident:(attachadditionalpageifnecessary)________________________________________________
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Employeeacknowledgement:MysignatureacknowledgesthatIhavereceivedthisreportandthatithasbeendiscussedwithme.Iunderstand
thatmysignatureisnotanadmissionoftheincidentoroffense.Iunderstand
thatImayappealthisreportbyfollowinginstructionsintheStaff
Handbook.
EmployeeSignature_________________________________________________Date:_____________________________________
WitnessSignature(ifany)_____________________________________________Date:_____________________________________
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