EMPLOYEE COUNSELING REPORT
Employee Name: ___________________________________
Department: _____________________
Date: ________________
VIOLATION:
[ ] Poor Performance
[
[ ] Absence/Tardiness
[
[ ] Violation of Company Policy
[
[ ] Violation of safety rules
[
[ ] Other ______________________________
ACTION TAKEN:
[ ] Verbal Warning
[ ] Written Warning
[ ] Second Written Warning
[ ] Termination (effective __ / __ / __)
]
]
]
]
Insubordination
Attitude
Leaving work without permission
Violation of Confidentiality
[ ] Investigative Suspension (beginning __/ __ / __)
[ ] With Pay
[ ] Without pay
If unsubstantiated, employee returned to work __ / __/ __
[ ] Disciplinary Suspension ____ days (__ / __ / __ - __ / __ / __)
[ ] With Pay
[ ] Without pay
EXPLANATION OF OFFENSE: Record complete, accurate, and unbiased facts. All persons, places, and records
mentioned should be properly identified. Use additional page if necessary.
DISCUSSION
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CORRECTIVE ACTION RECOMMENDED
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EMPLOYEE COUNSELING REPORT
EMPLOYEE’S COMMENTS
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This report will be made a part of your service record. Continuation of the behavior identified herein will subject you to
further disciplinary action, up to and including termination.
Employee Signature: My signature does not imply agreement or disagreement but is for the purpose of acknowledging
that the counseling report has been discussed with me.
Employee Signature: _________________________________________
Date: ________________________
Management Signature(s): A Manager may review this Employee Counseling Report and sign below after review of the
document.
Supervisor/Manager Signature: _________________________________________ Date: _________________________
Director of HR Signature: __________________________________________
Date: ________________________