EMPLOYEE INCIDENT AND DICIPLINE DOCUMENTATION FORM

Employee Information
Employee Name Employee Job Title

Incident Information
 Absent from work  Late to work  Other / to /

If absent/late to work, list date(s): From

Received Doctor’s note:  Yes  No Other incident: Date of Incident Description of Incident: /

Witness(es) to incident ________________________________________________________

Action Taken
What action was taken against the employee?  Spoke to employee  Terminated employee  Other

Did the employee offer any explanation for the conduct? If so, what was it?

Manager’s Signature

Date

EMPLOYEE INCIDENT AND DICIPLINE DOCUMENTATION FORM

Manager’s Signature

Date

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