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Disciplinary Write-Up Form Template

When an employee incites an incident in the workplace, swift action must be taken to discourage such behavior with a disciplinary action write-up template. Whether the employee is consistently late to work, engaging in inappropriate behavior, or has made a costly mistake, you can use this template to help get them back on track. This checklist template contains the following fields:

  • • Violation
  • • Violation description
  • • Action
  • • Consequences of further infractions
  • • Acknowledgement and sign off

You might also be interested in the employee incident report form and the non-conformance report.

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Disciplinary Write-Up Form Template



Employee Name

Picture of violation

Violation Date & Time

Type of warning

Other description:

VIOLATION DESCRIPTION (check all that apply)

Tardiness / Leaving Early


Violations of Company Policies

Drinking / Drugs at Work

Damage to Material/ Equipment / Property

Failure to come to work prepared

Substandard Work

Violation of Safety Rules

Unsatisfactory Behavior Towards Others

Tardiness or Absenteeism

Dress Code Violation


Other description:

Description of Violation - Specifics





Consequences of Further Infractions





Acknowledgement (Check Proper Box)

I agree with the violations identified in this report

I disagree with the violations identified in this report because:

(check name not set)

Employee Signature

Manager Signature

Witness Signature

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