Division of Business Affairs
Department of Human Resources
Progressive Discipline / Corrective Action / Probation Extension Form
Employee:
*
Incident Date:
*
-
Month
-
Day
Year
Date
Position:
*
Department.:
*
Time in Present Position:
*
Date of Hire:
*
-
Month
-
Day
Year
Date
LIST SPECIFIC ISSUES RELATED TO THE NATURE OF THE PROBLEM (include details, facts, specific dates, names, sequence of events, attach any supporting documentation, etc.):
*
NATURE OF PROBLEM (reference page 82 of the Staff Handbook for examples):
*
OTHER PROBLEMS IN THE PAST SIX MONTHS:
*
CORRECTIVE ACTION TAKEN:
*
Verbal Warning
Written Warning
Dismissal
Disciplinary Probation
Suspension
Written Warning:
Disciplinary Probation:
Suspension for:
Was the employee advised of his/her appeal rights under the employee discharge procedure?
*
Yes
No
Employee Signature
:_________________________________________________________________________________________________
Supervisor Signature:
________________________________________________________________________________________________
You selected NO, provide a DETAILED explanation as to why employee was not advised of appeal rights.
*
SPECIFIC PLAN FOR CORRECTION:
*
SPECIFIC TIMELINES (progress to be measured within these specified time periods) :
*
In regards to Action Taken:
I agree with action taken
I disagree with action taken
Employee Signature: _______________________________________________________________________________________________________________
Supervisor Signature:
________________________________________________________________________________________________
Supervisor E-Mail Address
If the employee declines to sign, the supervisor must initial under “Employee refuses to sign” and refer the employee to the Affirmative Action/EEO Office.
Employee refuses to sign - Supervisor Signature:
___________________________________________________________________________
DISSEMINATION OF COPIES AS FOLLOWS:
ORIGINAL:
• Human Resources
COPIES:
• Employee
• Department Supervisor
Attachment(s) As Necessary
Select File
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of
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