Employee: _____________________________________ Job Title: ______________________________________
1. The incident prompting this warning:______________________________________
________________________________________________________________________
________________________________________________________________________
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________________________________________________________________________ 2. Date, time and location of incident: _______________________________________
3. Policies violated: ______________________________________________________
4. Witnesses to incident: _________________________________________________
5. The disciplinary action being imposed consists of:
Written warning
Suspension as follows: __________________________________________
Demotion as follows: ____________________________________________
Probation as follows: ____________________________________________
Other: _________________________________________________________
6. It is essential that you address and correct the problem by doing the following:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________ Supervisor/Manager: ____________________________________ Date: ___________
EMPLOYEE: Please sign to indicate you received a copy of this warning/disciplinary action. PLEASE NOTE, If you fail to take advantage of this opportunity to correct the problems described above, or if additional problems emerge with your performance or conduct, you will be subject to further disciplinary action up to and including termination of employment.
Employee signature:______________________________________ Date:__________