"Employee Counseling Form - Life University"

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Employee Counseling Form
Employee Name __________________________________________________________________________________
Date of Notice ____________________________________ Date of Violation _________________________________
Nature of Violation
Poor Performance
Insubordination
Absence/Tardiness
Falsification of Documents/Records
Violation of Company Policy
Harassment
Other _________________________________________________________________________________________
Action Taken
Verbal Warning
Suspension
Written Warning
Termination
Other _________________________________________________________________________________________
Summary of Violation
(Attach any additional documentation)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Summary of Corrective Plan of Action
(Attach any additional documentation)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Follow up date(s) __________________________________________________________________________________
Employee Signature _______________________________________________________ Date ____________________
Supervisor/Manager Signature ______________________________________________ Date ____________________
Human Resources Received _________________________________________________ Date ____________________
The University reserves the right to begin the performance improvement process at any level. Under appropriate circumstances,
suspension may be immediate. The form of discipline depends on the circumstances, including performance, attendance, and
behavior issues.
The employee signature is intended only to acknowledge receipt of the notice; it does not imply agreement or disagreement
with the notice itself. If the employee refuses to sign, the supervisor/manager will be asked to initial the form indicating that the
employee received a copy of the form.
rev. 6/06
Employee Counseling Form
Employee Name __________________________________________________________________________________
Date of Notice ____________________________________ Date of Violation _________________________________
Nature of Violation
Poor Performance
Insubordination
Absence/Tardiness
Falsification of Documents/Records
Violation of Company Policy
Harassment
Other _________________________________________________________________________________________
Action Taken
Verbal Warning
Suspension
Written Warning
Termination
Other _________________________________________________________________________________________
Summary of Violation
(Attach any additional documentation)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Summary of Corrective Plan of Action
(Attach any additional documentation)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Follow up date(s) __________________________________________________________________________________
Employee Signature _______________________________________________________ Date ____________________
Supervisor/Manager Signature ______________________________________________ Date ____________________
Human Resources Received _________________________________________________ Date ____________________
The University reserves the right to begin the performance improvement process at any level. Under appropriate circumstances,
suspension may be immediate. The form of discipline depends on the circumstances, including performance, attendance, and
behavior issues.
The employee signature is intended only to acknowledge receipt of the notice; it does not imply agreement or disagreement
with the notice itself. If the employee refuses to sign, the supervisor/manager will be asked to initial the form indicating that the
employee received a copy of the form.
rev. 6/06