EMPLOYEE INCIDENT AND DICIPLINE DOCUMENTATION FORM

Employee Information

Employee Name Employee Job Title

Incident Information

 Absent from work  Late to work  Other

If absent/late to work, list date(s): From / to /

Received Doctor’s note:  Yes  No

Other incident:

Date of Incident /

Description of Incident:

Witness(es) to incident ________________________________________________________

Action Taken

What action was taken against the employee?

 Spoke to employee  Terminated employee  Other

Did the employee offer any explanation for the conduct? If so, what was it?

Manager’s Signature Date

 EMPLOYEE INCIDENT AND DICIPLINE DOCUMENTATION FORM

Manager’s Signature Date