DISCIPLINARY ACTION FORM
Name of Employee
*
First Name
Last Name
ID
Disciplinary Action
*
Tardiness
Absenteesim
Insbuordination
Work Performance
Dress Code
Safety
Substance Abuse
Policy Violation
Other
List Other:
If applicable, please list the HCCSC Conduct Policy(s) violated:
*
Date of Occurrence
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
II. Details of Occurrence
*
III. Has this, or a similar infraction occurred before?
*
Yes
No
If Yes, please provide the details below and attach prior disciplinary actions:
First Occurrence Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Action Taken
*
Second Occurrence Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Action Taken
Third Occurrence Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Action Taken
Additional Disciplinary Reports
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IV. Corrective actions to be taken:
*
Verbal Warning
Written Warning
Disciplinary Suspension
Final Warning
Reassignment
Termination
Loss of Professional Point
Termination Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
V. Expected Improvement
Name of Supervisor
*
First Name
Last Name
Email of Supervisor
*
example@example.com
Submit
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