Employee Name:
Date of Incident:
Position:
Department:
Action Taken: Verbal Written Suspension Termination
Nature of Incident: Unexcused Absense Drinking/Drugs while on Duty Personal Appearance/Hygiene Lack of Cooperation/Teamwork Tardiness Threatening or engaging in violence Destruction of Company Property Leaving without Permission Harassment Theft Insubordination Other
Facts of Incident:
Employee's Comments:
Timetable for Improvement: Immediate 30 Days Other
Other Notes:
Consequences of failure to improve: Suspension Immediate Termination
YOUR SIGNATURE INDICATES ONLY THAT YOU HAVE READ AND UNDERSTAND THE ABOVE. Employee Signature: (Type full name)
Supervisor Signature: (Type full name)
Manager's Approval: (Type full name)
