Disciplinary Write-Up Form

First Name

Last Name

Date of Incident required

Additional Details:

Action Taken / Expected Improvement

A pay adjustment of $1.00 per hour will be deducted from the team member’s hourly rate for a period of one month, beginning on the date of the infraction. During this time, performance and conduct will be closely monitored.

At the end of the one-month period, an assessment will be conducted to determine progress and overall improvement.

If the issue has been corrected, the hourly pay will return to the regular rate.
If the issue persists, additional disciplinary actions may be taken.

I understand and agree that $1.00 per hour will be deducted from my hourly rate for one month starting on the date of the infraction. After one month, my performance will be reviewed. If improvement is shown, my pay will return to the regular rate. If not, further action may be taken.

Team Member's Signature

Date of Signature required

Your form has bee submitted.