A Behavior Intervention Plan is a plan used by the employee’s manager to alert an
employee to behavior or performance issues that are assessed by the manager. This
form includes an instructions page, as well as a template that examines the types of
unacceptable behavior, a description of the actual behavior or performance issues
committed by the employee, the corrective action taken, a behavior improvement plan to
be implemented by the manager, and any other comments made by the employee.
This document is most useful for Human Resource Departments, and managers who
want to implement a plan of action to correct employee behavior or performance issues.
Behavior Intervention Plan Template
1. Employee Name: Name of employee receiving the intervention.
2. Date: Date the form is completed.
3. Department: Employee’s home department.
4. Date of Incident: Date the incident occurred that prompted an intervention
5. Unacceptable Behaviors: Put an X in the box before the type of incident. Managers
should refer to the employee handbook or specific company policies for explanation of
unacceptable behaviors included in this list. All forms must be reviewed by the human
resources department before meeting with the employee.
6. Other: Give details of the incident here.
7. Summary of Incident/Violation: Describe the incident in detail, with names of all
persons involved and any witnesses to the incident.
8. Corrective Action: Put an X in the box before the type of corrective action taken. If the
employee was terminated, put the termination date (last day worked) in the space
9. Behavior Improvement Plan: Give specific details of the action plan(s) to improve the
employee’s behavior, including actions employee needs to take and performance
improvement standards/measurements. Also include consequences or additional
interventions if employee does not meet improvement standards by required date.
10. Employee Comments: Employees can add any comments they may have regarding the
11. Follow-up Dates: List follow-up dates for the employee and manager.
12. Employee Signature/Date: The employee’s signature indicates they are aware of the
behavior intervention and behavior action plan. It indicates agreement with the summary
statement or an admission of guilt.
13. Manager Signature/Date: The form must be signed by the manager who completed the
14. Human Resources Signature/Date: The human resources representative who reviewed
the form should sign and date the form.
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Behavior Intervention Plan Template
Employee Name: Date:
Department: Date of Incident:
This intervention was prompted by the following unacceptable behavior(s):
Inappropriate Dress Insubordination
Excessive breaks Smoking in unauthorized areas
Personal use of company equipment Social networking
Theft Refusal to follow instructions
Giving misleading information Gossiping
Substandard performance Sleeping on the job
Falsification of timesheet Leaving the job without authorization
Unsafe work practices Violation of company policy
Other (please explain below)
Summary of Incident/Violation:
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Verbal warning Written warning
Suspension with pay Suspension without pay
Suspension pending further investigation Termination (Date:
Behavior Improvement Plan:
Follow Up Date(s): __________________ ___________________ ___________________
Employee Signature: ____________________________________ Date: ________________
Manager Signature: ____________________________________ Date: ________________
Human Resources Signature: _____________________________ Date: ________________
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INFORMATION AND FORMS ARE