Fillable Printable 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:

Date Type Details Written Report Prepared:

Yes No

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