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EMPLOYEE DISCIPLINARY REPORT Employee: Department: Today’s Date: Check which disposition was addressed today and will become part of the employee’s official personnel file: Oral Warning 2nd Written Warning/Reprimand Suspension Without Pay 1st Written Warning/Reprimand Suspension With Pay Dismissal Check the offense(s) below that the employee violated: Absence-Abuse Disrespectful to Supervisor or Co-workers Political Activities on the Job Absence-Leaving Without Permission Failure to Report Felony or Misdemeanor Profanity-Use of Absence-Unreported Harassment Safety Rules-Violation of Alcohol/Substance Abuse-Reporting Under the Influence of Housekeeping/Cleanliness-Failure to Maintain Smoking Policy-Violation of Bribes-Acceptance of Improper Conduct-Failure to Meet Department Standards Tardiness Confidential Information-Misuse Insubordination-Failure to Follow Orders Violence in the Work Place Defective and Improper Work Internet Abuse Wasteful of Material, Property, or Working Time Destruction of County Property Personal Appearance Other: Dishonesty Phone/Fax/Technology Abuse Incident Description (Detail facts below, and attach additional sheet(s) if necessary.) The employee that is subject to this disciplinary form should review and sign below to acknowledge receipt. If there is a refusal to sign, then a witness signature will be required. If this report is completed after an employee is terminated, a witness signature can be used to signify that the information on the report is accurate and was discussed with the employee. Employee Signature: Date: Witness Signature (Only If Employee Refused to Sign or Report Completed After Employee Terminated): Date: Department Manager Signature: Date: Division Director Signature: Date: Human Resources Director Signature: Date: Revised 9/11/23 Employee ID