EMPLOYEE COUNSELING FORM

Version No :

Approved by :

Effective Date :

EMPLOYEE NAME:EMPLOYEE ID:

DEPARTMENT:

SUPERVISOR / MANAGER NAME:

DATE:

REASON FOR COUNSELING: (check all that apply)

ATTENDANCE TARDINESS

PERFORMANCE INSUBORDINATION

FAILURE TO FOLLOW INSTRUCTIONS POLICY VIOLATION

TYPE OF COUNSELING: (check one)

VERBAL WARNING WRITTEN WARNING FINAL WRITTEN WARNING

SUSPENSION TERMINATION

AREA(S) OF CONCERN:

SUPERVISOR COMMENTS:

WAS EMPLOYEE PROVIDED WITH A COPY OF THE COMPANY POLICY PERTAINING TO THIS MATTER?

YES NO

EMPLOYEE COMMENTS:

NOTICE TO EMPLOYEE: Your signature only indicates your supervisor has discussed this matter with you and has explained the organization’s policy regarding this matter.

Employee Signature Date

Supervisor Signature Date

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