Employee Write Up Form Example

EMPLOYEE PERFORMANCE AND CONDUCT DISCIPLINARY ACTION RECORD

Document Control

• Effective Date: [Date]
• Version: 1.0
• Jurisdiction: [State/Province/Country]
• Classification: Restricted / Personnel File

I. LEGAL NOTICE AND DISCLAIMER

This document serves as an official record of disciplinary action. It is not an employment contract, nor does it alter the "at-will" nature of the employment relationship, where applicable. The execution of this form does not waive [Company Name]’s right to further disciplinary action, including termination, should performance or conduct fail to meet company standards. All entries herein shall be kept in the strictest confidence, subject to applicable labor laws and data privacy regulations.

II. PARTIES AND INCIDENT IDENTIFICATION

• Employer: [Company Name] (the "Company")
• Employee: [Full Legal Name] (the "Employee")
• Employee ID: [ID Number]
• Supervisor/Manager: [Name and Title]
• Date of Incident: [Date] | Location: [Location/Department]

III. OPERATIVE CLAUSES

1. Nature of Violation The Employee is being formally disciplined for the following reason(s):

• Performance Deficiency
• Policy/Procedural Violation
• Insubordination
• Attendance/Punctuality
• Conduct/Behavioral Issue
• Other: [Specify]

2. Statement of Facts Provide a concise, objective description of the incident, citing specific dates, times, and policy sections violated. Avoid subjective characterizations. [Detailed factual narrative]

3. Corrective Action Plan (CAP) The Employee is required to adhere to the following directives to rectify the aforementioned issue:

• [Required Action 1]
• [Required Action 2]
• [Required Action 3]

4. Timeline and Expectations Progress shall be monitored over a period of [Number] days. Failure to show immediate and sustained improvement may result in further disciplinary action, up to and including termination of employment.

IV. ACKNOWLEDGMENT AND SIGNATURES

Employee Statement: I acknowledge that I have received this disciplinary notice and have had the opportunity to discuss it with my supervisor. My signature does not necessarily indicate agreement with the contents, but confirms receipt of the document and the expectations outlined herein.

Employee Comments (Optional): [Space for Employee rebuttal or additional context]

Execution:

Employee Signature: ___________________________ Date: _______________

Manager Signature: ____________________________ Date: _______________

Witness/HR Representative: ____________________ Date: _______________

V. EXECUTION GUIDE FOR OPERATIONS

1. Fact-Finding: Before issuing, ensure all factual assertions are supported by documentation (emails, logs, previous performance reviews). Do not include hearsay.
2. Private Consultation: Present this document in a private, one-on-one setting. Ensure a witness (typically an HR representative) is present if the nature of the discipline is severe.
3. Procedural Review: Allow the employee time to read the document in its entirety. If the employee refuses to sign, note "Employee refused to sign" on the signature line, have the witness sign below that notation, and file accordingly.
4. Distribution: Provide the employee with a copy immediately upon execution. File the original in the employee’s secure personnel file. Flag the review date in the Company HRIS/Calendar for a follow-up assessment.