Record of Discipline and Point Assignment Form

* = Required Information

Record of Discipline (completed by HR or Director)

* Complete a separate form for each separate discipline issue, even if the infractions are related or on the same day. Additional points may be issued if the same infraction occurred multiple times (complete a separate form).

Points Issued

Name of Employee with performance infraction

First Name *

Last Name *

Date of Counsel

Date of infraction *

Location of Infraction *

Were there any witnesses to the infraction (if applicable). Use initials if the witness is a client.

Policy or Procedure violated (Include specific employee action(s) related to performance concern)

Expectations given to the employee for future performance

Explain why the employee was aware that the infraction was contrary to performance expectations (cite specific policy or supervisor directive, including dates)

Employee Response

Was the employee retrained in the violated policy or protocol?

Yes

Name of the supervisor issuing the discipline/performance counsel

Name of the Human Resources staff or other participant in the discipline/performance counsel

Signature