Notification of Violation of Policies

and/or Procedures

The following employee is hereby notified of a violation of policies and/or procedures:

GENERAL INFORMATION

Employee Name

Job Title

Employee Status. Check all that apply:

Part-time Full-time Temporary Probationary Trainee Hourly Paid Salaried

SUMMARY OF RULE VIOLATION

Check One:

Performance of Duties Failure in Personal Conduct

Section(s) of personnel policy that apply to this violation:

Summary (include date of offense):

(Attach additional page if necessary)

RECOMMENDED DISCIPLINARY ACTION

Check appropriate space for current action, and include dates of previous disciplinary warnings:

STEP 1: Oral	Warning issued on	STEP 3:	Final Warning:	Date	Date

ST'EP 2:	Written Warning	STEP 4:	Termination:

Date	Date

Disciplinary Recommendation(s):

Disciplinary Probation/Number of Days:	Reduction in Pay	Disciplinary Transfer

Suspension/Number of Days:	Check One: With Pay	Without Pay

Corrective Action Plan: ):

EMPLOYEE ASSISTANCE PROGRAM

Has a previous EAP referral been made: - No	Yes	If "Yes", "date":

Is the employee being referred to EAP now for assistance?	No	Yes

If "No', why? ):

EMPLOYEE COMMENTS

The employee is encouraged to comment on the allegations contained herein, the supervisor's recommendations for disciplinary action, and the proposed corrective action plan. The employee is not obligated to submit a statement):

(Use additional pages if necessary)

I acknowledge that I have been provided with a copy of allegations made against me and the proposed disciplinary and corrective actions. I have also been advised of the City's grievance procedure and understand that if a grievance is contemplated, I have five (5) working days to file an action. My signature is not intended to indicate agreement with any of the statements made about me, but indicates only my awareness of the allegations, proposed disciplinary actions, and proposed corrective action plans that affect me.

Issuing Supervisor	Employee

Date	Date

Witness (if the employee refuses to sign)

Date

ADNMINISTRATIVE REVIEW SECTION

Supervisors on the chain of command are to indicate that they either "Agree" or "Disagree" with the issuing supervisor's recommendations for disciplinary action, or any modifications to the original disciplinary or corrective action recommendations.

Agree	Disagree

Department Head's Signature and Date

Agree	Disagree

City Manager's Signature and Date (if applicable)

(Any changes in the disciplinary action or corrective action plan recommended by the issuing supervisor must be justified)

Modifications to the Recommended Disciplinary Action or Corrective Action Plan,

Signature, Title, and Date

CC: PERMANENT PERSONNEL FU.E

CITYNEW PER.