Employee Performance Counseling
Employee Name: SS#:
Position: Supv. Name: Date:
This record is designed to document a negative incident and should be placed in the employee’s file. The purpose is to build a
picture of the employee’s performance to aid management in the proper evaluation of job related performance.
DATES OF PREVIOUS COUNSELING Verbal Initial Warning Final Warning
PERFORMANCE VIOLATION(s)
1 Unlawful Discrimination / Sexual Harassment 16 Sleeping, malingering, or loitering on the job
Falsification of records or misleading statement or Working unauthorized overtime or refusing assigned
2 17
omission. Committing a fraudulent act. overtime
3 Falsification of time worked, time cards, or reports 18 Safety, health, or security violations
Theft or Unauthorized removal of Co. funds or
4 19 Abusive, Profane, or Obscene language on job
property
Unauthorized use or misuse of company Unprofessional, rude or discourteous behavior to
5 20
equipment, time, materials, or facilities customer, employee or vendor or customer complaint.
Working under the influence of alcohol while
6 21 Inability to complete or pass training
working
Use, possession, or distribution of drugs or failure, Mishandling of client information causing errors in
7 22
inconclusiveness, or refusal of drug/alcohol test service, reporting, or account information
Excessive or inappropriate communication of a
8 23 Excessive use of phone for Personal Phone Calls
personal nature on company time
Unauthorized possession of firearms or dangerous
9 24 Dress Code or Grooming Violation
weapons
Unsatisfactory performance, Failure to complete
Failure to report work related: misconduct, criminal
10 25 work, Not maintaining minimum acceptable job
activity, or suspicion to management
requirements
Improper conduct, Insubordination, Failure to carry Causing, creating, or participating in a disruption of
11 out a reasonable request of an appropriate 26 any kind during working hours or on company
supervisor property
12 Failing to notify Supervisor when unable to work 27 Failure to provide requested documentation
13 Leaving Dept. w/o permission or Notifying Mgmt. 28 Change in Work Availability not approved by Mgmt.
Failure to observe schedule: Unexcused and / or Improper use or breach of confidentiality, trust
14 repeated tardiness and / or absenteeism and / or 29 and/or disclosure of company or personnel
excessive breaks information
Other:
15 Abusing PTO or LOA policies 30
* Some violations may result in immediate termination
What is the SPECIFIC ISSUE/ PROBLEM or opportunity for improvement? (Indicate where applicable the policy, rule,
or regulation affected.)
How does the issue / problem / condition impact work? (Provide examples)
What is the previous history or events? (Describe the history, with dates if available, or whether issue/problem is
new.)
What is the expected SPECIFIC ACTION PLAN for continued improvement or behavior? (Recommended to list
steps or action to be taken)
What is the time frame for improvement, if necessary? (Give concise dates as to what is expected and when;
establish follow-up date.)
What are the consequences of non-improvement? (If changes do not occur, what will happen?)
Follow-up (if required): Date: Time: Place:
SUPERVISOR / MANAGER ACKNOWLEDGMENT & ACTION TAKEN (* Requires Mgmt. Review & Approval)
Verbal Warning Initial Warning Final Warning ( ) Day Probation*
Demotion* (Performance Issues only) Separation/Termination* Suspension* _______days - ( w/Pay or w/out Pay)
For all warnings and suspensions:
The Warning and/or Suspension period begins (the date this official warning is given):
The Warning period ends (generally a 6 –12 month probation period from last repeated occurrence)
During the Warning period there should be a formal follow-up conversation to review Progress vs. Specific Actions(s) required.
This should be done __________days after the warning is given.
I acknowledge that I have discussed this warning / acknowledgement with the employee, set an action plan and have given him/her
a copy (if so asked) and the original signed copy has been recorded in the employee’s personnel file.
Immediate Supervisor/Manager: _____________________________________________Date: ___________________
Next Level Supervisor/Manager/Owner: ______________________________________ Date: ___________________
EMPLOYEE ACKNOWLEDGMENT
I acknowledge that this issue or problem was discussed with me and I may receive a copy if requested and that this will also
become a part of my personnel record.
I acknowledge that failure to correct this situation within the time frame indicated will result in further counseling action up to
and including termination of employment.
Comments: _______________________________________________________________________________________________
Employee Signature: Date:
