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Fillable Printable Employee Write Up Disciplinary Report Form

Fillable Printable Employee Write Up Disciplinary Report Form

Employee Write Up Disciplinary Report Form

Employee Write Up Disciplinary Report Form

Disciplinary Report Form*
Employee Name:Job Title:
Department:Supervisor:
Date/Time of Occurrence:Location:
Type of offense:
_____Absenteeism_____Smoking in undesignated area
_____Tardiness_____Posting items without permission
_____Leaving work area without permission_____Fighting or creating conflict
_____Misuse of property/equipment_____Using vulgar language
_____Leaking confidential information_____Rudeness
_____Theft or fraud_____Abusiveness
_____Lying or cheating_____Bringing weapon onsire
_____Falsifying documents_____Bringing illegal drugs/alcohol onsite
_____Unsafe behavior/horseplay_____Failing to follow instructions
_____Poor work quality_____Insubordination
_____Poor work quantity_____Sleeping on the job
_____Poor hygiene_____Disregarding dress code
_____Other_____Other
Facts of Incident:(Attach additional page if necessary)
Past Disciplinary Action:
DateTypeDetailsWritten Report Prepared:
YesNo
YesNo
YesNo
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 Staff Handbook.
Employee Signature
Date:
Witness Signature (if any)Date
*Complete immediately and forward within three (3) business days to: Director of Human Resources
HR form/9/2007
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