Disciplinary Form

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1.  Name _____________________________________________  Date _______________________

	Job Classification _________________________________________________________

	Date of Hire _____________________  Supervisor _____________________________

2.  Discipline Taken: Written Warning ___ Reprimand ___ Suspension ___ Discharge ___ 

	Other ______________________________________________________________________

	Reason (Attach additional sheet, if necessary): ____________________________

	____________________________________________________________________________

	Rule or Policy Violated: ___________________________________________________

	____________________________________________________________________________

3.  Prior Disciplinary Record: _____________________________________________________

	____________________________________________________________________________


________________________________________________	____________________________
Signature of Supervisor					Date


________________________________________________	____________________________
Signature of Personnel Director				Date


________________________________________________	_____________________________
Signature of Employee*					Date
*BY SIGNING THIS DISCIPLINARY FORM, THE EMPLOYEE MERELY ACKNOWLEDGES THAT HE OR SHE 
HAS READ IT, NOT THAT HE OR SHE AGREES WITH ITS CONTENTS.
                                                                                                                                      
Summary of Disciplinary Conference (to be completed by supervisor):

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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