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Disciplinary Request

This document is a request for disciplinary action form to be completed by a supervisor after an incident involving an employee's performance or conduct that may warrant discipline. The supervisor is instructed to prepare an incident summary, obtain witness statements, and review the summary with their department head before submitting to labor relations. The form requests details of the incident including names, dates, locations, witnesses, and a description of the employee's actions. The supervisor and department head must sign to request an investigation to determine if disciplinary action is needed.

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28 views

Disciplinary Request

This document is a request for disciplinary action form to be completed by a supervisor after an incident involving an employee's performance or conduct that may warrant discipline. The supervisor is instructed to prepare an incident summary, obtain witness statements, and review the summary with their department head before submitting to labor relations. The form requests details of the incident including names, dates, locations, witnesses, and a description of the employee's actions. The supervisor and department head must sign to request an investigation to determine if disciplinary action is needed.

Uploaded by

PHILPOT222
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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REQUEST FOR DISCIPLINARY ACTION

INSTRUCTIONS: This summary is to be prepared by a supervisor immediately after an incident involving an


employee’s performance or conduct occurs when the supervisor has a reasonable basis to believe that discipline may
be warranted.
THINGS TO DO:
-Prepare this Incident Summary.
-Obtain signed witness statements.
-Review the completed Incident Summary with your Department Head or Director promptly and have
them sign in the space provided below.
-Submit completed Incident Summary, witness statements and any evidence to Labor Relations – For Time and
Attendance issues please submit copy of last written counseling and appropriate time sheets.
-Call Employee and Labor Relations if you have any questions.

INCIDENT SUMMARY
Please Print
Employee Name:______________________________________ Title: ________________________
Status: Probationary / Temporary / Term / Permanent Shift:_________________________
Date of Incident:______________ Time of Incident:___________ Location of Incident: ____________
Witnesses: Name(s)____________________________________ Work Phone Number____________
Did you personally witness incident?_____________________________________________________
If not, how did you become aware of incident? _____________________________________________
When did you become aware of the incident?______________________________________________
Did the incident involve a patient/guest/student?____________________________________________
If so, did the patient/guest file an incident report?___________________________________________
Describe what happened in detail, i.e., actions and/or statements of the employee(s), instruction to
employee(s), statements of witnesses, physical evidence, and your remarks, what did the employee(s)
and you do or say .

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

______________________________________
Signature of Supervisor/ Date

------------------------------------------------------------------------------------------------------------------------------------------------------
To: Labor Relations: Please investigate this incident to determine if disciplinary action is warranted.

Employee and Labor Relations:


Campus Zip Phone Fax ______________________________________
West Campus 0751 632-6140 632-2544 Signature of Department Head/Director
HSC/UH 8229 444-3780 632-2545
LISVH 9500 444-8617 444-8517

Labor Relations Form: Request for Discipline (5/09)

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