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: