"Employee Counseling Statement Template"

ADVERTISEMENT
ADVERTISEMENT

Download "Employee Counseling Statement Template"

Download PDF

Fill PDF online

Rate (4.8 / 5) 19 votes
Employee Counseling Statement
Employee Name_______________________________________
Date_______________
Reason for Conference
_____ Violation of Center Policy/Procedure
_____ Suspension Pending Investigation
_____ Sub-Standard Job Performance
_____ Other
What Policy(ies), Procedure(s), Standard(s) was not followed?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Details of the Incident/Allegation
What Specifically Occurred
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
When (Date and Time)
Date____/____/____
Time________________
Where (Location, Classroom, Area of Classroom)__________________________________________
How (What Lead to Incident)__________________________________________________________
Who Reported Incident (may omit for confidentially purposes)_______________________________
Were there witnesses (may omit names for confidentiality purposes) ___________________________
Investigation of Incident
Did the Employee admit violating policy/procedure/standard? _____ Yes _____ No
Were witnesses interviewed? _____ Yes
_____ No
Summary of Investigation:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Previous Counseling of Employee on Performance
_____Verbal
Date____/____/____
Concern Addressed_________________________
Employee Counseling Statement
Employee Name_______________________________________
Date_______________
Reason for Conference
_____ Violation of Center Policy/Procedure
_____ Suspension Pending Investigation
_____ Sub-Standard Job Performance
_____ Other
What Policy(ies), Procedure(s), Standard(s) was not followed?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Details of the Incident/Allegation
What Specifically Occurred
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
When (Date and Time)
Date____/____/____
Time________________
Where (Location, Classroom, Area of Classroom)__________________________________________
How (What Lead to Incident)__________________________________________________________
Who Reported Incident (may omit for confidentially purposes)_______________________________
Were there witnesses (may omit names for confidentiality purposes) ___________________________
Investigation of Incident
Did the Employee admit violating policy/procedure/standard? _____ Yes _____ No
Were witnesses interviewed? _____ Yes
_____ No
Summary of Investigation:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Previous Counseling of Employee on Performance
_____Verbal
Date____/____/____
Concern Addressed_________________________
_____ Written
Date____/____/____
Concern Addressed_________________________
_____ Written
Date____/____/____
Concern Addressed_________________________
_____ Written
Date____/____/____
Concern Addressed_________________________
_____ Performance Appraisal
Date____/____/____
Concern Addressed____________________
Counseling Statement Results
_____ Unfounded (Employee may return to work)
_____ Written Warning: (Employee may return to work knowing future warnings could result in termination.)
_____ Termination
Outcomes:
Future Expectations of Employee to avoid a similar incident:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Consequences if expectations are not met, performance isn't improved, or other violations are repeated:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Employee Comments
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Employees Signature: ________________________________________________________________
Director's Signature: _________________________________________________________________
Witness Signature: __________________________________________________________________
Page of 2