Fill and Sign the What Can Employers Ask About an Employees Medical Form

Basic form © James R. McDade, (ver: 02-24-06) 209-667-2300 EMPLOYEE COACHING FORM Employers use this form to record and notify an employee of performance issues. Delete this note prior to use.Employee’s Name: Position: 1. R eco rd d ate s a n d d escrip tio n o f w hat h ap pen ed (observable behavior):2. If applicable, what was the employee’s response:3. Was a rule or directive broken?  Yes  No Describe rule or directive: 4. Did the employee know of the rule or directive?  Yes  No How did employee know of rule or directive?  Common Sense  Prior Meeting  Handbook  Training  Verbal Warning  Written Warning  Other: 5. Did anything contribute to the incident such as system limitations or physical barriers to performance? No  Yes, describe: 6. D escrib e p ast r u le v io la tio ns o r p erfo rm an ce i s su es a n d t h e d is cip lin e g iv en :7. D escrib e m it ig atin g c ir c u m sta n ces, s u ch a s p ast g ood p erfo rm an ce, l e n gth o f e m plo ym en t, e tc :8. Disciplinary measure to be given employee:  Verbal Warning  Written Warning  Final Written Warning  Suspension for ____ days without pay  Termination  Other:9. C orre ctiv e a ctio n t o b e t a ken b y e m plo yee, i f a p plic ab le :1 0. P ote n tia l F utu re C onseq uen ces: If t h e e m plo ye e c o ntin ues t o v io la te t h e s a m e o r o th er C om pany r u le s a nd perfo rm ance s ta ndard s, o r f a ils t o f o llo w t h e c o rre ctiv e a ctio n r e quir e d in t h is c o unse lin g f o rm , t h e e m plo ye e m ay b e g iv e n a fin al w arn in g, s u sp ended w it h out p ay, o r h ave e m plo ym ent t e rm in ate d, d ependin g o n t h e c ir c u m sta nce s. A s w it h a ll dis c ip lin a ry w arn in gs, n o m in im um n um ber o r f o rm al o rd er is r e quir e d p rio r t o a t e rm in atio n o f e m plo ym ent.S up erv is o r's S ig natu re : _ __________________________________ D ate : _ _________________________If n eede d, s ig na tu re o f w it n ess a ckn ow le dgin g e m plo ye e r e ce iv e d c o py o f t h is f o rm : _ ______________________ E M PLO YEE'S A CKNO W LE D G EM EN T A ND C O M MEN TS ___ ___ In it ia l h ere if y o u, t h e e m plo ye e, a gre e t h at t h e f a cts s e t f r o th a bove a ccu ra te ly d escrib e t h e in cid ent._ __ ___ In it ia l h ere if y o u, t h e e m plo ye e, d is a gre e w it h t h e f a cts d escrib ed a bove , a nd t h en d escrib e t h e f a cts a s y o u k n ow them o n t h e b ack o f t h is f o rm . I a ckn ow le dge t h at I h ave r e ce iv e d a c o py o f t h is c o unse lin g f o rm . I a ls o u nders ta nd t h at c o m ple tio n o f t h e d is cip lin ary me asu re o r c o rr e ctio n a ctio n d oes n ot c h ange m y " a t- w ill" e m plo ym ent s ta tu s w it h t h e C om pany, a nd I c a n le ave o r b e te rm in a te d w it h o r w it h out c a use o r p rio r n otic e ._ __ ___ _______________________________________ _ ______________________________E m plo ye e's S ig natu re D ate