Source: AGSAFE

Disciplinary action checklist

Items that should be included in a Notice of Disciplinary Action. 
1. Date of Notice

2. Employee Name

3. Supervisor Name

4. Type of Problem or Violation  
a. Tardiness
b. Absenteeism
c. Insubordination
d. Quality of Work
e. Quantity of Work
f. Safety
g. Drug or Alcohol Abuse
h. Other

5. Details of Occurrence
a. Date of Occurrence
b. Description

6. Corrective Action

7. Expected Improvement

8. Consequences of Failing to Improve

9. Employee Statement

10. Acknowledgement Statement:
a. By signing this notice I am acknowledging that I have been counseled about my inappropriate conduct and informed of consequences if improvements are not made. 

11. Employee Signature and Date