Medina County Commissioners
DISCIPLINARY/COUNSELING REPORT
Name: ______________________ Dept.: _____________________ Date: _______
Time of Meeting: ________________
AM PM
ACTION
:
Counseling Verbal Warning Written Warning Suspension: _____ # Days Termination
List date(s) of previous counseling or disciplinary action(s) and attach copies of previous actions
which this report is based upon:
___________________________________________________________________________________
DESCRIPTION OF ISSUE
(Attach additional comments if more space is required):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Further violation of Medina County policies will result in additional disciplinary action up to and
including removal. By signing below you acknowledge you have received this notice.
Employee: _______________________________________________ Date: __________
Supervisor: ______________________________________________ Date: __________
Witness: ________________________________________________ Date: __________
Copy Distribution:
1. Human Resources
2. Department file
3. Employee
Discipline Action.doc Resolution 07-900
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