EMPLOYEE COUNSELING FORM
Department of Human Resources
EMPLOYEE COUNSELING FORM
Employee Name: Click here to enter text. Time of Counseling: Click here to enter text.
Supervisor Name: Click here to enter text. Location of Counseling: Click here to enter text.
Department: Choose an item. Nature of Counseling: Choose an item.
Date of Occurrence: Click here to enter a date. Type of Discipline: Choose an item.
Date of Counseling: Click here to enter a date.
Why is the employee receiving counseling? (Discuss the behavior displayed by the employee and
review the policy/policies relevant to this behavior)
Click here to enter text.
Has the employee been counseled for similar behavior in the past? If so, please list the dates of
counseling and what was discussed in the counseling session
Click here to enter text.
Describe the consequences for this behavior and the consequences if the behavior continues. Also
discuss how the behavior is affecting the team or organization.
Click here to enter text.
Specifically Discuss Employee Expectations in the Future.
Click here to enter text.
Set a date to follow-up and discuss status of behaviors relevant to expectations set with the
Employee. What behaviors will you follow-up on specifically?
Click here to enter text.
Updated 7/2016
Supervisor Signature Date
Dept. Head Signature Date
HR Director Signature Date
(Signature only required for disciplinary action above verbal counseling/verbal reprimands)
EMPLOYEE REMARKS CONCERNING COUNSELING
(The absence of any statement on the part of the EMPLOYEE indicates his/her acknowledgement of this report as stated.)
(If additional pages are required, please attach.)
I have read this counseling report and understand it. I understand that I have an opportunity to make a statement regarding this
report in the space provided above. As a regular full-time or regular part-time employee, I further understand that, in accordance
with the City’s Progressive Discipline and Disciplinary Appeals Policy, I have the right to appeal this disciplinary action with the
if
City Manager within five (5) business days from receipt of this disciplinary action this disciplinary action resulted in my
termination, demotion, or suspension lasting more than three (3) work days,
Employee Signature Date Attachments:
Choose an item.
Distribution of Copies
DirectorSupervisorEmployeeHuman ResourcesPersonnel File