Sample Written Warning Form

Employee's name: ____________________________________________

Date of conversation: __________________________________________

Specific rule violation or performance problem: _____________________

_____________________________________________________________

Previous conversations about the rule violation or performance problem:

_____________________________________________________________

_____________________________________________________________

Specific change in the employee's performance or behavior that is expected:

_____________________________________________________________

_____________________________________________________________

Employee's comments: __________________________________________

_____________________________________________________________

Supervisor's comments: __________________________________________

_____________________________________________________________

Employee's signature: ____________________________________________

OR

Employee was asked to sign this written warning on ______ but declined to sign.

Supervisor: _____________________________________________________

Date: __________________________________________________________