Information
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Store #
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Date of counseling
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Prepared by
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Location
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Employee name
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Date of Occurrence
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Action Taken
- Verbal Counseling
- Written Counseling
- Termination
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Type of occurrence
- Policy/Rules
- Performance
- Safety
- Attendance/Tardiness
- Conduct
- Other
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Describe Issue/Conduct to be Addressed
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Describe Expected Conduct
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Employee Comments
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If unacceptable conduct continues further action may be taken, up to and including termination of employment. I understand that signing this document merely indicates that I have been advised of the action taken and the possible future action(s) My signature does not indicate agreement with counseling.
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Employee
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Manager/Supervisor
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Witness
