Disciplinary Action Form

• Job Name

• Job Number

• Prepared by

VIOLATION

• Employee Name

• Picture of violation

  Media

• Violation Date & Time

  Date

• Type of warning

  Verbal Warning

  Written Warning

  Serious Warning

  Other

• Other description:

VIOLATION DESCRIPTION (check all that apply)

• Drinking / Drugs at Work

• Dishonesty

• Failure to carry out instructions of a supervisor with respect to job responsibility

• Deliberate abuse or destruction of company property

• Not wearing proper PPE

• Other description:

• Horseplay

• Fighting on the jobsite

• Disabling or unhooking safety devices

• Housekeeping (or lack there of)

• Violation of safety rules

• Failure to report injury or property damage accident

• Absenteeism

• Tardiness

• Poor work ethic

• Other:

• Other description:

• Description of Violation - Specifics

Action

• Warning

• Suspension

• Dismissal

Consequences of Further Infractions

• Warning

• Demotion

• Suspension

• Dismissal

Acknowledgement (Check Proper Box)

• I agree with the violations identified in this report

• I disagree with the violations identified in this report because:

• Employee statement

• Employee Signature

  Sign

• Supervisor Signature

  Sign

• Witness Signature

  Sign