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