Team Member Name: ___________________________________ Team Member Role:______________________________
Date of Counseling: __________________________________
Supervisor’s Name: __________________________________ Date of Incident: _________________________________
| Reason for Counseling |
| Circle One: Tardiness/AbsenceBehavior/TeamworkInappropriate Conduct/DressPoor PerformanceSafety ViolationViolation of Company Policy Other: ____________________________________________________________________________________________________ |
| Action Taken |
| Circle One: Verbal Warning Written Warning Suspension Probationary PeriodTermination Other: ____________________________________________________________________________________________________ |
| Description of Incident |
| Summary of Corrective Action(s) to be Taken |
Signature of Employee: _______________________________________________________________________________
Signature of Supervisor Administering Counseling: ________________________________________________
