Disciplinary Action Form

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Updated 4.2021

Employee Name*
Department*
Date of Disciplinary Action*
MM slash DD slash YYYY
Issuing Manager*
Issuing Manager Email*
Additional Manager Email

Optional
Type of Incident
Level of Disciplinary Action
Details of the Incident*
Timetable for Improvement*
Employee Coments
You are formally being warned to bring to your attention the severity of this situation. A copy of this report will be submitted to Human Resources and retained in your personnel file.

Failure to correct this behavior and/or further violation of company policy will result in additional disciplinary action, up to and including discharge. By signing below, you acknowledge that you have received this notice.
Check if Employee Requests a Copy
- Employee Copy Requested
Employee Email*
Employee Present to Sign Form*
- Yes
- No
Employee Signature*
If employee signs, they are entitled to a copy of this form. If they would like a copy, provide their email below.
Date Signed*
MM slash DD slash YYYY
Issuing Manager Signature*
Date Signed*
MM slash DD slash YYYY

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