ISI EMPLOYEE DISCIPLINARY REPORT

Employee Name:

Employee Number:

• Date of Incident

  Date

Time of Incident:

Offense Number: 1___ 2___ 3___

• Date of Last Offense:

  Date

• Prepared by

• Location
  Address

NATURE OF INCIDENT

• 1. Unexcused Absence

• Under the Influence of Drugs / Alcohol

• Dishonesty

• Violation of Conduct Rules

• Improper Conduct

• Carelessness

• Tardiness

• Insubordination

• Destruction of Company Property

• Theft

• Violation of Safety Rules

• Failure to Follow Instructions

• Substandard Work

• Leaving without Permission

Other

• Cause for Disciplinary Action?

  Yes

  No

  N/A

• Future Action to be Taken by Employee?

  Yes

  No

  N/A

• Action Taken by Supervisor?

  Yes

  No

  N/A

• Verbal Warning

• Written Warning

• Suspension

• Termination

Other

Employees Comments

I HAVE READ AND ACKNOWLEDGE RECEIPT OF THIS REPORT, along with any additional comments or other paperwork that may be attached to this report.

• Employee Signature

  Sign

• Date

  Date

• Supervisor Signature

  Sign

• Select date

  Date

• Witness Signature

  Sign

• Select date

  Date

Copy to: (1) Employee (2). Supervisor (3). Personnel File The above offense(s) have been noted and are made part of the employee's permanent personnel file.