DISCIPLINARY/COUNSELING REPORT

Name: Employee ID: Date:

Date of Occurrence: Time of Occurrence: Location:

Action Taken:
Coaching Written warning Suspension (days)
Verbal warning Termination Other

(Note that the above action descriptions do not represent steps to be followed. Any of the above actions may be
taken at any time depending on the nature of the offense.)

Description of Issue
Absence Safety violation Conduct
Tardiness Policy violation Performance issue
Other

Explanation/Comments: (You may attach additional pages if necessary.)

Goal(s)/Corrective action(s):

My signature below acknowledges that I have formally been warned about the situation referenced in this document. I acknowledge
I understand that failure to correct this behavior and/or any further violation of company policy will result in additional disciplinary
action up to and including immediate termination.

Employee: Date:

Supervisor: Date: