This Disciplinary Action Form is used by an employer as a part of its disciplinary
program. This form should be used as a procedure to preserve a record of an
employee's non-performance or misbehavior in the workplace. It also offers the
employee ways to improve performance or correct behavior and explains the potential
consequences if the problem is not corrected. Documentation of employee discipline is
important for fairly informing an employee of performance problems and for creating a
trail of documentation for potential legal actions. This form is useful to companies when
dealing with employees with performance or behavioral issues.
Record of Disciplinary Action
[Company Name]
[Company Address Line 1]
[Company Address Line 2]
Employee Name:
Employee Department:
Date Action Taken:
Reason for Disciplinary Action: (check all that apply)
___Quality ___Safety ___Conduct ___Attendance ___ Insubordination ___ Other
Employee:
You are receiving this disciplinary action because your behavior in regard to the
documented incident constitutes a failure to comply with [Company] personnel policies,
[Company] employee manual, and/or acceptable business practices. By conducting yourself in
this way you have placed [Company] and/or your fellow [Company] employees in an injurious
position.
The specific incident or behavior that has led to you receiving this disciplinary action is
described as follows: (describe behavior/incident in detail)
Undesired behavior/incident:
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Effect of undesired behavior/incident on [Company] or employees of [Company]:
What is expected/desired from Employee in regard to behavior/incident:
Disciplinary Action:
As a consequence of your behavior or conduct in regard to this discipline report,
[Company] has decided to make the following actions, pursuant to [Company] discipline policy
(check appropriate step):
_____ Reprimand
_____ Written Warning
_____ Suspension With Pay
_____ Suspension Without Pay
_____ Demotion – Loss of Duty
_____ Employment Termination
Unless this problem is corrected, future disciplinary action will also be taken up to and including
the termination of your employment, pursuant to [Company] discipline policy (check appropriate
step):
_____ Reprimand
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_____ Written Warning
_____ Suspension With Pay
_____ Suspension Without Pay
_____ Demotion – Loss of Duty
_____ Employment Termination
Employee Comment:
Pursuant to [Company] policy of promoting fairness and employee input, you have the
opportunity to provide your comment on this disciplinary action. (Employee Comment):
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Employee:
I have received this disciplinary action and understand the disciplinary action taken. I also
understand that unless this problem or behavior is corrected, further disciplinary action will be
taken up to and including the termination of my employment pursuant to [Company] policy.
Employee’s Signature: _______________________________________Date:______________
Supervisor:
I have reviewed this Discipline Report with Employee, and have described to Employee all
disc