"Disciplinary Action Checklist & Approvals" - Florida

The Florida Department of Juvenile Justice has released this version of the "Disciplinary Action Checklist & Approvals" on May 1, 2010.

This form may be used by all Florida residents: download the printable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Disciplinary Action Checklist & Approvals" - Florida

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STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
CONFIDENTIAL
DISCIPLINARY ACTION CHECKLIST & APPROVALS
EMPLOYEE’S NAME (PRINT):
DATE:
Title:
Position Number:
PF ID #:
REGION:
CIRCUIT:
Facility/Unit:
Requestor:
Phone #:
EMPLOYEE STATUS:
Probationary
(Has not attained Permanent Status in any class)
Probationary
(Has previously attained Permanent Status
Permanent
(Has completed a probationary period)
Selected Exempt Service
OPS
TYPE OF DISCIPLINE REQUESTED:
Oral Reprimand
Dismissal
Suspension:
Number of Days Requested
Written Reprimand
Extraordinary Dismissal
Demotion
Abandonment
HAS EMPLOYEE BEEN REMOVED FROM CLIENT CONTACT?
Yes
No
N/A
HAS AN I.G. INVESTIGATION BEEN CONDUCTED?
Yes
No
N/A
If Yes: Date Completed:
BRIEF DESCRIPTION OF EMPLOYEE HISTORY
1. Length of Service with State of Florida:
Years
Months
2. Length of Service with DJJ:
Years
Months
3. Agency Hire Date:
4. Last three Performance Ratings:
(Attach Appraisals)
5. Counseling and Disciplinary History:
REASON FOR DISCIPLINARY ACTION:
1. List the specific DMS Standard(s) of Conduct, which the employee violated:
2. State the specific reason(s) for disciplinary action:
Revised 05/10
1
STATE OF FLORIDA
DEPARTMENT OF JUVENILE JUSTICE
CONFIDENTIAL
DISCIPLINARY ACTION CHECKLIST & APPROVALS
EMPLOYEE’S NAME (PRINT):
DATE:
Title:
Position Number:
PF ID #:
REGION:
CIRCUIT:
Facility/Unit:
Requestor:
Phone #:
EMPLOYEE STATUS:
Probationary
(Has not attained Permanent Status in any class)
Probationary
(Has previously attained Permanent Status
Permanent
(Has completed a probationary period)
Selected Exempt Service
OPS
TYPE OF DISCIPLINE REQUESTED:
Oral Reprimand
Dismissal
Suspension:
Number of Days Requested
Written Reprimand
Extraordinary Dismissal
Demotion
Abandonment
HAS EMPLOYEE BEEN REMOVED FROM CLIENT CONTACT?
Yes
No
N/A
HAS AN I.G. INVESTIGATION BEEN CONDUCTED?
Yes
No
N/A
If Yes: Date Completed:
BRIEF DESCRIPTION OF EMPLOYEE HISTORY
1. Length of Service with State of Florida:
Years
Months
2. Length of Service with DJJ:
Years
Months
3. Agency Hire Date:
4. Last three Performance Ratings:
(Attach Appraisals)
5. Counseling and Disciplinary History:
REASON FOR DISCIPLINARY ACTION:
1. List the specific DMS Standard(s) of Conduct, which the employee violated:
2. State the specific reason(s) for disciplinary action:
Revised 05/10
1
ATTACHMENTS:
Please attach ALL relevant documents. All items must be included, submitted to, and approved by the appropriate
reviewing authority before any disciplinary action is taken. Place a check mark next to all attachments that are
included.
Copies of previous disciplinary history (including relevant counseling memo’s)
Witness list
Copy of DJJ Handbook receipt signed by employee
Copy of last three performance evaluations
Copy of I.G. Report (if applicable)
N/A
Copy of Internal Investigation Completed at facility
Chronology of Events
Pre-Investigative Conference Notes (Questions and Responses)
All Applicable Facility Operating Procedures (FOP’s)
Proposed Draft Letter (relates to All types of disciplinary actions)
All other Supporting Documentation
Copy of Videotape (if applicable)
NA
Relevant training records showing training provided to employee
N
C
AME OF
ONTACT WHO WILL
A
G
C
:
SSIST
ENERAL
OUNSEL
T
C
:
T
. #:
ITLE OF
ONTACT
EL
F
. #:
AX
P
A
W
:
ROPOSED
GENCY
ITNESSES
(Attach brief written statements as to what the witness will testify to)
EMPLOYEE NAME
YES/NO
ADDRESS
TELEPHONE#
Y
N
Y
N
Y
N
Y
N
Y
N
Revised 05/10
2
AUTHORIZATION TO FORWARD TO OFFICE OF GENERAL COUNSEL:
Approved
Supervisor Signature
Print Name
Date
Not Approved
Comment(s):
Approved
Superintendent/Chief Probation Officer
Print Name
Date
Not Approved
Signature
Comment(s):
Approved
Regional Office Personnel Liaison
Print Name
Date
Not Approved
Signature
Comment(s):
Approved
Region Chief/Director Signature
Print Name
Date
Not Approved
Comment(s):
Approved
Assistant Secretary/ELT Member
Print Name
Date
Not Approved
Signature (if applicable)
Comment(s):
Date forwarded to General Counsel Office
Revised 05/10
3
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