Employee Disciplinary Action Form

Please select your role in the disciplinary action:*
Employee:*
Date of Warning:*
MM slash DD slash YYYY
Department:*
Supervisor:*
Type of Violation*
- Attendance
- Carelessness
- Disobedience
- Safety
- Tardiness
- Work Quality
- Other
Violation Date:*
MM slash DD slash YYYY
Violation Time:*

: Hours

Minutes

AM/PM
Place Violation Occured:*
Employee Section
Employee Statement:
Consent*
I have read this “warning decision”. I understand it and have received a copy of the same.
Employee Name*
First Last
Date*
MM slash DD slash YYYY
Employer Section
Employer Statement:
Warning Decision:
Approved By:

Must provide Name, Title, & Date of Approval
Please List All Previous Warnings (when warned and by whom):
Date: Verbal: Written:
Consent*
I have read this “warning decision”. I understand it and have received a copy of the same.
Name of Person Who Prepared Warning*
First Last
Date
MM slash DD slash YYYY
Supervisor's Name:*
First Last
Date*
MM slash DD slash YYYY

Date:	Verbal:	Written:

Employee Section