(see the reverse side for directions)

PG.01.1(1) Discipline Action Form(see the reverse side for directions)The purpose of this action is to notify the employee that a change of behavior on the job is required to complywith the agency's policies, procedures, practices or expectations.Section 1Employee: Position: Loc#____________This is a(n): Awareness warning Critical warning Final WarningDate of incident:Description of incident: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________Corrective action or training agreed upon: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Section 2I understand that if I do not meet the requirements agreed to above, the next step will be: Critical warning Agreement for Continued Employment Final Warning DischargeStatement by employee (optional): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Section 3I understand what is expected of me and will do my best to comply.I also understand that I have the right to use the Employee Appeal Procedure, PG.02.01, if I do not agree with thisaction. I also understand that I must comply with the above agreement until my appeal is heard.Signed:Signed:__________________________________________________ Date: __________________________Employee__________________________________________________ Date: __________________________SupervisorPrinted Name of Supervisor: ____________________________________________________________________Witness Signature: ___________________________________________________________________________Copy of Appeal Procedure Received: (please initial) ______

PG.01.1(1) Discipline Action FormDirections for Completingthe Disciplinary Action FormSection 1If the action is an "Awareness Warning", you must discuss the need for corrective action with your supervisorwho must also sign the form. Check the "Awareness Warning" box. Describe the problem in enough detail that itwill be understood by someone not familiar with the person/situation.If the action is a "Critical Warning", discuss the need for corrective action with your supervisor or someone in theHuman Resources Department. Check the "Critical Warning" box. Describe the problem in enough detail that itwill be understood by someone not familiar with the person/situation.If the action is a "Final Warning" for attendance, discuss the need for corrective action with your supervisor orsomeone in the Human Resources Department. Check the "Final Warning" box. Describe the problem in enoughdetail that it will be understood by someone not familiar with the person/situation.Section 2Check the appropriate box for the next step to be taken if the problem is not corrected:If this disciplinary action is an "Awareness Warning", the next step is a "Critical Warning", so check that box.If this disciplinary action is a "Critical Warning", the next step is an "Agreement for Continued Employment", socheck that box. If it is a "Critical Warning" for attendance, the next step is a "Final Warning", so check that box.If this disciplinary action is a "Final Warning", the next step is "Discharge", so check that box.If this disciplinary action is an "Agreement for Continued Employment", the next step is "Discharge", so checkthat box.Section 3After discussing the changes that are necessary to avoid future disciplinary actions, present the form to theemployee to sign. If the employee refuses to sign it, you may sign it and note on it that the employee refused tosign it.Provide the employee with a copy of the employee appeal procedure.Send this form immediately to the Human Resources Department. You may keep a copy for yourself as long as itis secured to maintain confidentiality. The employee may have a copy if requested.