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Employee Name

Last 4 SSN

Date +

Suspension Period

Paid

Unpaid

Start Date +

End Date +

Termination

Yes

+ Effective Termination Date

Description of offense

Corrective action required: in which case there would be severe consequences

Consequences:
Employee is expected to take responsibility for his/her behavior and understand that in accordance with Company policy, a repetition of this offense or acts of a similar nature will be subject to further corrective action, up to and including termination of employment. The Company reserves the right to bypass corrective action counseling steps when circumstances warrant it.

Employee Signature

I acknowledge that this notice has been reviewed with me. I understand its contents and that it will become part of my personnel file.

Employee Signature Date +

Employee Email Address

Signature Field Employee

clear

Foreman Signature

Foreman Signature Date +

Foreman Email Address

Signature Field Foreman

clear

Superintendent Signature

Superintendent Signature Date +

Superintendent Email Address

Superintendent Field Foreman

clear

Completed form will be sent to all email addresses entered on this form plus a copy goes to Human Rescources.

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Safety Violation	Attendance	Job Performance	Company policy or rule violation
Verbal Counseling	Written Warning	Suspension	Termination