Polly Management Disciplinary Report Form
Unit
*
Please Select
10100- Bloomfield DQ
11125- Ligonier DQ
11449- Middlebury DQ
11651- Goshen DQ
11683- Winona Lake DQ
11658- Forest Park
11659- Kokomo DQ
11662- N. Manchester DQ
11664- Plymouth DQ
11668- Bremen DQ
11674- Lincolnway DQ
11675- Huntington DQ
11792- Thorntown DQ
12477- Nappanee DQ
12500- Syracuse DQ
12601- Delphi DQ
12733- State Line DQ
12816- Huntingburg DQ
12933- Mishawaka DQ
13370- West Jefferson DQ
13512- Markle DQ
14292- Albion DQ
41009- 231 South DQ
41037- Illinois Rd DQ
40574- 26 East DQ
41682- 38 East DQ
46107- Gas City DQ
41314- Purdue West DQ
Q5025-Noble Romans Lafayette, IN
Q5059-Noble Romans Kokomo, IN
2525 - Pepe's
Admin
Employee Name
*
First Name
Last Name
Date of Incident
-
Month
-
Day
Year
Date Picker Icon
Report Details / Narative
Policy Violation
Please Select
N/A
Section 1A: Uniforms
Section 1B: Grooming
Section 1C: Customer Interaction
Section 1D: Restaurant Facility and Premesis
Section 1E: Cash Handeling
Section 1F: Scheduling
Section 1G: Payroll
Section 1H: Privacy of Information
Section 1I: Food Purchases and Meals
Section 1J: Restaurant Telephone Use
Section 1K: Cell Phones, Electronic Devices, and Personal Items
Section 1L: Smoking
Section 1M: Sickness and Emergencies Before Work
Section 1N: Accident/Injury While at Work
Section 1O: Employee Fraternization
Section 1P: At Will Employee Statement
Section 1Q: End of Employment Statement
Section 1R: Immediate Notification of Store/District Manager
Section 1S: Policy Update and Modification
Section 1T: Contact Upper Management
Section II-A-1: Dishonesty
Section II-A-2: Theft
Section II-A-3 Unexcused Absences
Section II-A-4: Consumption of Alcohol or Illegal Drugs
Section II-A-5: Engaging in Sexual Relations
Section II-A-6: Insubordiantion
Section II-A-7: Willful Contamination of any Product
Section II-A-8: Harrassment of Any Kind
Section II-A-9: Actions that put health or saftey of persons at risk
Section II-A-10: Violation of Smoking Policy
Section II-A-11: Verbal Abuse of Persons
Section II-A-12: Physical abuse of Persons
Section II-A-13: Engaging in Illegal Behavior
Section II-A-14: Failure to Report Injury
Section II-A-15: Job Abandonment
Section II-B-1: Violation of Uniform Policy
Section II-B-2: Violation of Personal Appearance Policy
Section II-B-3: Violation of Personal Grooming Policy
Section II-B-4: Rudeness Towards Employees or Customers
Section II-B-5: Violation of Any Personal Conduct Policy
Section II-B-6: Violation of any Attendance Policy
Section II-B-7: Lack of Productivity While at Work
Action Taken
*
Please Select
Official communication to employee.
Verbal Warning. Employee has been verbally warned. No signature required
Written Warning - Employee signature required
Final Warning- Further policy violations will result in termination of employment. Employee signature required
Suspension of Employment for 1 week from the date of this document. Employee signature required
Suspension of Employment for 2 weeks from the date of this document. Employee signature required
Probation. Any further violations of any company policy within 30 days will result in termination of your employment. Employee signature required
Termination of Employment
Reporting Manager
First Name
Last Name
Signature
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