Disciplinary Action Report
Employee's Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Site and Shift
Type of Violation
Attendance
Lateness/Leaving Early
Unauthorized Absence from Work Area
Substandard Work Quality
Drinking/Drugs While at Work
Carelessness
Violation of Company Policy
Willful Damage to Material/Equipment
Threatening or Engaging in Violence
Unfit for Duty
Insuborination
Violation of Safety Rules
Working on Personal Matters/Conflict of Interest
Unsatisfactory Behavior Towards Employees or Customers
No Call/No Show
Other
Time of Violation
Hour Minutes
AM
PM
AM/PM Option
Supervisor's/Employer's Statement
Employee's Statement
I agree with Supervisor's/Employer's Statement
I disagree with Supervisor's/Employer's Description of Statement for the reasons listed below
Employee was not present to sign or dispute when this form was completed
I disagree because:
Action to be Taken
Verbal Warning
Written Warning
Suspension
Dismissal
Other
Timetable for Improvement
Immediate
30 Days
60 Days
Other
Failure to Improve will Result In:
Warning
Suspension
Dismissal at a later Date
Immediate Discharge
Other
Supervisor/Employer Statement
Employee's Statement
For the Employee: I have read this Employee Disciplinary Notice and Understand it.
Supervisor/Employer's Signature
Supervisor Completing Form and Signing
First Name
Last Name
Did the Employee Sign this Form
Employee Refuses to Sign
Other
Employee's Email Address to Receive a Copy
example@example.com
Submit
Should be Empty: