Employee name: | Department: | Supervisor name:: |
Date of occurrence: | Time: | Location: |
The following counseling has taken place (check all that apply and give details in the summary below):
[ ] Absence | [ ] Harassment |
[ ] Tardiness | [ ] Dishonesty |
[ ] Violation of company policies and/or procedures | [ ] Violation of safety rules |
[ ] Horseplay | [ ] Leaving work without authorization |
[ ] Smoking in unauthorized areas | [ ] Unsatisfactory job performance |
[ ] Failure to follow instructions | [ ] Insubordination |
[ ] Unauthorized use of equipment, materials | [ ] Falsification of records |
[ ] Other | |
Summary of violation:
Summary of corrective plan of action:
Follow-up date(s):
Employee signature__________________________________________ | Date: __________ |
Supervisor signature: ________________________________________ | Date: __________ |
HR manager signature: _______________________________________ | Date: __________ |
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