Disciplinary Write-up

• Prepared by

• Employee Name

• Project

• Location
  Address

VIOLATION

• In violation of GCI policy

• Employee Name

• Employer Name

  Select GCI

  • GCI

• Picture of violation

  Media

• Violation Date & Time

  Date

• Type of warning

  Select Verbal Warning 1st Written Warning 2nd Written Warning 3rd Written Warning 4th Written Warning Serious Warning Other

  • Verbal Warning
  • 1st Written Warning
  • 2nd Written Warning
  • 3rd Written Warning
  • 4th Written Warning
  • Serious Warning
  • Other

• Sent home remainder of day

• Sent home remainder of day plus two more days (3days)

• Sent home for one week

• Sent home immediately and a meeting at the office with management is required before returning to work

• Serious Warning

• Other description:

• Employee may return to work on

  Date

SAFETY (check all that apply)

• Unsafe act

• Description

• Failure to wear PPE

• Description

• Working in Unsafe conditions or improper housekeeping

• Description

• Failure to follow safety procedures

• Description

• Other:

• Other description:

CONDUCT UNBECOMING OF A PLS PROFESSIONAL ( check all that apply )

• Working under the influence

• Lack of Productivity or failure to follow instructions

• Tardiness or Absenteeism

• Dishonesty

• Horseplay

• Other:

• Other description:

ADDITIONAL COMMENTS

Employee Statement (Check Proper Box)

• I agree with the violations identified in this report

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

• Employee Signature

  Sign

• Safety Representative Signature

  Sign