Employee Name: ______________________________________________________
First Middle Last
Department: ______________________________________________________
_____ Written Warning _____ Final Warning
1. Statement of the problem: ____________________________________________
_________________________________________________________________________
_________________________________________________________________________
2. Prior discussion or warnings on this subject, whether oral or written:
_________________________________________________________________________
_________________________________________________________________________
3. Company policy on this subject:_______________________________________
_________________________________________________________________________
_________________________________________________________________________
4. Summary of corrective action to be taken by the Company and/or employee:
_________________________________________________________________________
_________________________________________________________________________
5. Consequences of failure to improve performance or correct behavior:
_________________________________________________________________________
_________________________________________________________________________
6. Employee Statement:________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Employee Signature: __________________________________ Date: ____________
Management Approval: __________________________________ Date: ____________