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CORRECTIVE ACTION FORM

Today’s Date:

Employee Name: Branch Location: Account Name:

Date of Policy Violation or Incident: Reason for Notice:

Dates of Prior Counseling or Corrective Action:

Situation Statement: Describe the incident, event, or situation; use dates, times, names, and facts. If policy violation,
reference specific policy violation.

Actions to be taken: Examples include items such as appropriate standards, training, time frames, additional assistance
that will be provided, expectations of behavior, consequences for further violations, or failure to perform up to standards,
etc.

Employee Remarks: Use additional sheet if more space is needed.

Acknowledgement: I have read and understand this notice and have been given the opportunity to make appropriate
remarks. I further understand that improvement must be immediate and sustained. Failure to take immediate corrective
action may result in further corrective action, up to and including termination.

Employee Printed Name Employee Signed Name Date

Manager Printed Name Manager Signed Name Date

Witness Printed Name Witness Signed Name Date


Updated: Feb 2020

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