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Disciplinary Action Report

Capture workplace violations, the employee's response, and the improvement plan set by the supervisor.

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Employee's Name

First Name

Last Name

Date

Site and Shift

Type of Violation

Tardiness Absenteeism Insubordination Safety Violation

Time of Violation

Supervisor's/Employer's Statement

Employee's Statement

Agree Disagree

I disagree because:

Action to be Taken

Verbal Warning Written Warning Suspension Termination

Timetable for Improvement

Immediate 30 Days 60 Days 90 Days

Failure to Improve will Result In:

Suspension Termination Demotion

Supervisor/Employer Statement

Employee's Statement

For the Employee: I have read this Employee Disciplinary Notice and Understand it.

Sign here

Supervisor/Employer's Signature

Sign here

Supervisor Completing Form and Signing

First Name

Last Name

Did the Employee Sign this Form

Yes No

Employee's Email Address to Receive a Copy

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