Employee Reprimand Form

Information you will need

• What’s the employee's department?
• What's the employee's work ID number?
• Where did the violation occur?
• When did the violation occur?
• What was the violation?
• Is the employee being placed on administrative leave with pay?
• Is the employee being sent home with pay?
• Is the employee being suspended without pay?
• Is the employee being recommended for termination?
• Is a disciplinary action not listed here being taken?
• What disciplinary action is being taken?
• Is no disciplinary action being taken?
• When does the disciplinary action take effect?
• What corrective actions must be taken by the employee?
• What’s the name of the employee?
• What’s the name of the supervisor issuing this reprimand?
• Is the employee refusing to sign this form?
• How many days is the employee being suspended?
• How many days is the employee being placed on administrative leave?

Completed by the employee.

The form includes a notary acknowledgment.