Disciplinary Report Form * Employer Name:
Job Title:
Department:
Supervisor:
Date of Occurrence:
Location:
Type of Offense:
Sexual misconduct/harassment Bringing weapons on site Using/possessing/under influence of drugs/alcohol Insubordination Actual/threat of physical violence Intimidation/coercion Falsification of documents Unauthorized removal of church property Destroying/damaging property Moral breach Accepting bribes Theft
Job abandonment Violation of the Internet/email use Failure to meet job requirement Failure to notify of absence/tardiness Disrupting peace/unity Excessive tardiness/absenteeism Unsatisfactory work performance Violating safety/health rules Abusive/vulgar language Spreading gossip/false rumors Gambling Other
Facts of Incident: (Attach additional page if necessary)
Past Disciplinary Action: Date:
Type:
Details
Written Report Prepared: Yes
No
Yes
No
Yes
No
Consequence if incident occurs again:
Completed by:
Date:
Employee Statement regarding facts of incident: (Attach additional page if necessary)
Employee acknowledgment: My signature acknowledges that I have received this report and that it has been discussed with me. I understand that my signature is not an admission of the incident or offense. I understand that I may appeal this report by following instructions in Staff Handbook. Employee Signature Witness Signature (if any)
Date: Date:
_ _
* Complete immediately and forward within three (3) business days to: Executive Pastor with cc to Exec. Dir. Business Administration. Supervisor will keep a copy for the file.