Corrective Action Form

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CORRECTIVE ACTION FORM
Employee Name _________________________________________
Date _____________
Department ___________________________________________________________________
Position ______________________________________________________________________
Date of Incident _________________________________________
Time ____________
Reason for Corrective Action: ___________________________________________________
_____________________________________________________________________________
Details of What Happened: _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What is Wrong? How action effects operations? ____________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What must be done to correct problem? __________________________________________
_____________________________________________________________________________
Employee's Comments: ________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Supervisor's Comments: _______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Progressive Disciplinary Action Taken:
Verbal Warning
Follow-Up Meeting Date, if any ___________________________
Written Reprimand
Follow-Up Meeting Date, if any ___________________________
Employee's Signature _____________________________________
Date ____________
Supervisor's Signature ____________________________________
Date ____________
Original to Personnel File
Copy Appointing Authority
Copy Employee
Q:\HR\FORMS\CORRECTIVE ACTION FORM.DOC -- 5/10
CORRECTIVE ACTION FORM
Employee Name _________________________________________
Date _____________
Department ___________________________________________________________________
Position ______________________________________________________________________
Date of Incident _________________________________________
Time ____________
Reason for Corrective Action: ___________________________________________________
_____________________________________________________________________________
Details of What Happened: _____________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What is Wrong? How action effects operations? ____________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What must be done to correct problem? __________________________________________
_____________________________________________________________________________
Employee's Comments: ________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Supervisor's Comments: _______________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Progressive Disciplinary Action Taken:
Verbal Warning
Follow-Up Meeting Date, if any ___________________________
Written Reprimand
Follow-Up Meeting Date, if any ___________________________
Employee's Signature _____________________________________
Date ____________
Supervisor's Signature ____________________________________
Date ____________
Original to Personnel File
Copy Appointing Authority
Copy Employee
Q:\HR\FORMS\CORRECTIVE ACTION FORM.DOC -- 5/10

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