Page 39 - PL Handbook 2016

CORRECTIVE ACTION FORM

Employee’s Name Warning Date Shift Department

Verbal Counsel Type of Action: (Check one) Discharge
Verbal Warning Written Warning Suspension

Type of Violation: (Check one)

Attendance Safety Carelessness Insubordination Work Quality Core Values Other

Attach separate document if required

INCIDENT: Describe the situation (behavior, performance, policy violation, etc.) that occurred. Include date,
time, location, people involved, witnesses, effects of incident on employee’s work or other employee’s work
or other employees, and all other relevant circumstances or contributing factors. Please be specific in stating
observable behaviors and comments whenever possible.
INCIDENT WARNING: What specific actions, within what timeframe, are to be accomplished to improve
the behavior / performance? Describe what will happen if employee fails to meet the goals set within the
designated time frames.
EMPLOYEE’S COMMENTS: My supervisor has reviewed the above situation with me and my comments
are given below.

My signature indicates that this incident has been reviewed with me and I do do not, concur
with this statement.

Employee’s Signature Date

Supervisor’s Signature Date

Human Resources Signature Date

Prior Corrective Action Taken
Date:

None Verbal Verbal Written Suspension
Counsel Warning Warning

Purity Life Employee Handbook EDITION 2 - 2016 39