EMPLOYEE DISCIPLINARY ACTION FORM

EMPLOYEE DATE OF WARNING DEPARTMENT SUPERVISOR

TYPE OF VIOLATION WARNING

[ ] ATTENDANCE [ ] CARLESSNESS VIOLATION DATE:_____________________________________

[ ] SAFTEY [ ] TARDINESS
[ ] DISOBEDIENCE [ ] WORK QUALITY PLACE VIOLATION
[ ] OTHER ___________________________________________ OCCURRED:__________________________________________
___________________________________________________ ___________________________________________________
_ _

EMPLOYER STATEMENT

EMPLOYEE STATEMENT

WARNING DECISION

LIST ALL PREVIOUS WARNINGS (WHEN WARNED AND BY WHOM): I HAVE READ THIS “WARNING DECISION’. I UNDERSTAND IT AND
HAVE RECEIVED A COPY OF THE SAME.

1ST WARNING
DATE: ________________________________________________ | ______________________________________________________
VERBAL: ______________________________________________ | EMPLOYEE SIGNATURE DATE
WRITTEN: _____________________________________________|

2ND WARNING
DATE: ________________________________________________ | ______________________________________________________
VERBAL: ______________________________________________ | SIGNATURE OF PERSON WHO PREPARE WARNING DATE
WRITTEN: _____________________________________________|

3RD WARNING
DATE: ________________________________________________ | ______________________________________________________
VERBAL: ______________________________________________ | SUPERVIOSOR’S SIGNATURE DATE
WRITTEN: _____________________________________________|
COPY OF DISTRIBUTION
[ ] EMPLOYEE [ ] HR DEPT [ ] SUPERVISOR