EMPLOYEE DISCUSSION FORM
EMPLOYEE'S NAME:
SUPERVISOR'S NAME:
DEPARTMENT:
1. Was previous counseling session held? [ 1 Yes
2. Your performance has been found unsatisfactory for the reason(s) set forth below* [ ] Lateness [ ] Absenteeism [ ] Poor quality work [ ] Failure to follow procedure(s) [ ] Damaged equipment [ ] Refbsal to work overtime [ ] Insubordination [ ] Rude or disrespectful behavior [ ] Falsifying documentation [ 1 Volume of work produced [ ] Other (Explain Below) [ ] Ignored instructions given
Expectations of Supervisor: (Use back of form, if necessary)
Reviewed policies and procedures regarding this matter:
[ I Yes C I No
Explained to employee consequences if unsatisfactory performance continues.
[ I Yes [ I No
Employee asked questions or had input into conversation.
[ I Yes [ I No
Other information pertinent to counseling session:
Employee's Signature: Date:
Supervisor's Signature: Date:
Note: Employee's signature on this form verifies that the situation noted above has been discussed with himher and is not an admission of guilt or a confirmation that the infraction occurred. Employee's response to this discussion is on the back of this form.
EMPLOYEE'S RESPONSE:
EMPLOYEE'S SIGNATURE:
DATE:
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