DISCIPLINARY ACTION FORM

Office of Human Resources

300 Washington Avenue  Chestertown MD 21620

PHONE 410.778.7298  FAX 410.778.7254

EMAIL [email protected]

WEB hr.washcoll.edu

DISCIPLINARY ACTION FORM

Name of Employee: _________________________________________ ID#:_________________________

I. Disciplinary Action

 Tardiness  Absenteeism  Insubordination  Work Performance

 Dress Code  Safety  Substance Abuse  Policy Violation

 Other_________________________________________________________

If applicable, please list the Washington College Conduct Policy(s) violated:

_____________________________________________________________________________________________

II. Details of Occurrence (Attached additional sheet if necessary) Date of Occurrence:_________________________

_____________________________________________________________________________________________

III. Has this or a similar infraction occurred before?

 No Yes If yes, please provide the details below and attach prior disciplinary actions.

First Occurrence Date:_______________________ Action Taken:_________________________________________

Second Occurrence Date:_______________________ Action Taken:_________________________________________

Third Occurrence Date:_______________________ Action Taken:_________________________________________

IV. Corrective action to be taken:

 Verbal Counseling  Written Warning  Disciplinary Suspension  Final Warning

 Counseling with Human Resources  Termination Termination Date:___________________________

V. Expected Improvement:______________________________________________________________________

__________________________________________________________________________________________

Consequence for unsatisfactory improvement and/or further disciplinary actions:

 Verbal Counseling  Written Warning  Disciplinary Suspension  Final Warning  Termination

Supervisor Signature:_____________________________________________________ Date:__________________

VI. Employee Statement:________________________________________________________________________

__________________________________________________________________________________________

I acknowledge by my signature below that I have been given the opportunity to present my views and explanations and I

am singing this review prior to it being placed in my personnel file. I also understand the corrective actions to be taken by

my supervisor and consequences if my improvement is unsatisfactory or I receive further disciplinary actions.

Employee Signature: ______________________________________________________ Date:_________________