Preview Hospital Disciplinary Action Form

EMPLOYEE DEPARTMENT

Employee Relations Advisor Director, Human Resources Vice President

Verbal Warning / Counseling

Written Warning *** next annual merit increase

Two-day Suspension ***

Probation for Performance *** : (Start / End Dates)

Under Tardiness Policy: Probation *** Two Day Suspension ***

Suspension Pending Review of Recommendation to Terminate

The next disciplinary step for a violation of this same policy is:

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DISCIPLINARY ACTION FORM

HOSPITAL

WHITE = Copy to Employee Relations YELLOW = Copy to Employee PINK = Copy to Department File

Disciplinary Action Form_HR

Result in ineligibility for ***

My Signature Verifies I have Read This. It Does NOT Imply Agreement

with the time limits set forth in Hospital Policy and the Employee Handbook

Notice to Employee

: Any grievances filed in response to this disciplinary action must comply

For Infraction of Policy / Section:

Policy Language Being Applied / Summary of Facts Supporting Application of Policy:

PRIOR Disciplinary Actions During Last Twelve Months: (Cite Policy / Date / Disciplinary Action)

Consultation With:

This Disciplinary Action:

Supervisor Signature / Date:

Director / Nurse Manager Signature / Date:

Employee's Remarks:

Employee's Signature / Date:

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