Record of Counseling/Verbal Reprimand
Employee Name: _________________________ Empl. ID: ______________ Date: ________
Department: _____________________________ Place of incident: _______________________
Indicate if: [ ] Coaching/Counseling Session
[ ] Verbal Reprimand
The following counseling or verbal reprimand has taken place: (Check and give details under explanation)
[ ] Reporting late to work at the beginning of a shift or after the lunch period
[ ] Stopping work before or starting work after the designated time
[ ] Failure to follow or perform job duties or procedures as instructed
[ ] Failure to follow established leave request procedures/policies
[ ] Failure to punch your own time card at the beginning and end of each shift and lunch period as specified
[ ] Disregard of stated Department uniform and staff identification procedures and policies
[ ] Excessive absenteeism
[ ] Horseplay
[ ] Failure to maintain satisfactory working relations with employees, students or the public
[ ] Interference with other employees work
[ ] Smoking in unauthorized areas
[ ] Other ________________________________________________________________________________
Summary of incident and/or reason for warning: _________________________________________
________________________________________________________________________________
________________________________________________________________________________
Summary of corrective action needed: ____________________________________________
_________________________________________________________________________
_________________________________________________________________________
It is expected that the condition noted above will be corrected immediately. In the event this
condition is not corrected, or another offense occurs, you will be subject to further disciplinary action,
up to and including termination.
Employee Signature______________________________________
Date_______________
(Your signature is intended only to acknowledge receipt of the notice; it does not imply agreement or
disagreement with the notice itself. If you refuse to sign, someone in a supervisory position will be
asked to initial the form indicating that you received a copy of the form.)
Supervisor Signature______________________________________
Printed Name of Supervisor_________________________________
NOTE: If verbal reprimand, send a copy to Human Resources
Record of Counseling/Verbal Reprimand form
Revised 07/2006
Date_______________