Disciplinary write up
Employee Name & Title (caregiver)
Full Name
Title
Date of Incident
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Department
Date Issued
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Issuing Supervisor’s Name
Subject: Check violation category
Attendance Conduct
Performance
Other
Please check
Employed less than 30 days
Employed more than 30 days less than 90
Employed more than 90 days
Nature(s) of incident
ATTENDANCE
Of attendance policy. i.e., Excessive tardiness and / or absences
Improper use of time-keeping system. i.e., Not punching / falsifying time
Unauthorized overtime
No call, no show
Violating Lunch/Break time policy
CONDUCT
Violation of the business code of conduct policy including disruptive behavior / outburst / arguing / fighting / threating and/or possession / use of weapon on premises
Distributing/ Selling / and or using alcohol or illegal drugs on premises
Falsifying information regarding personal work history, background, skills, or training
Eating on the floor or cell phone usage violation
Insubordination. Refusing to follow direct order from supervisor/manager. disrespectful conduct towards management
Sexual or other unlawful or unwelcome harassment of co-workers or building tenants /visitors. Gossiping or spreading rumors about co-workers /defamation of character
Sleeping / nodding on the job. Loitering / not working
Violation of dress code policy
Theft of property including accounts. Damaging property
Unauthorized disclosure of confidential information.
PERFORMANCE
Unsatisfactory work performance
Other policy violations are not listed above.
Please specify in remarks below
Supervisor/Manager Remarks (Brief description of violation)
Suspension Start Date
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Return Date
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Other
Employee Signature
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HR/Owner/Supervisor or Manager Signature
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HR/Owner/Supervisor or Manager Signature
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