Title Page
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Performance Discussion Record
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Team Member Name
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Date:
Performance Discussion Record
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Team Member Name
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Date:
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Job Title
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Department
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Start Date:
The incident detailed on this form is in breach of policy and procedures. The level of warning and action taken will depend on the severity of the incident. Should the incident be serious enough, dismissal (in some cases - instant) may result.
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Has the team member been counselled / warned on previous occasions:
Reason for discussion Describe in specific detail the reason for the discussion including all aspects of the unsatisfactory performance / behaviour / conduct. Include relevant history leading up to this performance meeting (date, time, location, verbal discussions). If there is sufficient room, please attach extra paper. Number allegations where there is more than one.
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Reason for discussion
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Statement of Business Expectations
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Record of Team Member Comments
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Outcome as a Result of Counselling Interview
- counselling only
- verbal warning
- first warning
- final warning
- first and final warning
- termination
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Agreed Actions For Improvement
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Review of team members behaviour is due on (one month after counselling)
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Date of Review
Consequences of Continued Unsatisfactory Performance Clearly detail the next action that will follow on the issue being addressed if there is no improvement or there is a repeat incident. Further breaches of policies and procedures
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Next action taken if further breaches of policies and procedures
The details shown above have been explained to me and I understand that a copy of this document will be retained on my personal file. I understand the consequences of not correcting the performance or behaviour discussed with me.
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Team Member Name
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Date:
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Witness Name
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Date:
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Witness Name
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Date:
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Position
Team Member Review
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Date:
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Clearly detail how the team member has progressed since the warning was issued - what improvement has occurred/what improvement is still required/have all agreed actions been completed?
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Human Resources Signature
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Manager/Supervisor Signature:
