08/18 HR-7
This is to inform you that consideration is being given to taking disciplinary action against you, up to and including
termination of employment, under the following Policies, Procedures and/or Rules:
(Describe the incident(s) and list all rule/policy violations.)
At this time, your employment with the City has not been terminated. Disciplinary action, if any, has not been
decided; however, termination of your employment may be a possible outcome;
You are entitled to a tape recorded pre-termination hearing with management regarding the above incident(s);
You will be provided a brief description of the alleged incident/infraction(s); you will have an opportunity to
respond. This is not an appeal hearing; no witnesses will be called;
If you are placed on paid administrative leave, you must respond within two (2) hours to any communication you
receive from the City and be available to meet as directed. Failure to comply with this directive may result in
you being charged accrued leave (PTO or Vacation) or leave without pay if you have no leave.
During this time period you must refrain from going to your work location or doing any work unless directed by
your Division Manager. All keys, badges, cell phone, equipment, will be collected from you until a final
decision is made.
You may waive your right to the pre-termination hearing by signing below; this decision will not affect your
appeal rights;
The date, time, and location of the hearing: ____________________________________________________
Attendance will be limited to the employee and Management(s) representative.
____________________________________ ______________________________________________
Employee Signature and Date If Employee Refuses To Sign: Witness Signature and Date
(Signature only indicates that I have read and (If employee refuses to sign, supervisor
understand the contents of this document) should read the above in presence of witness & employee)
After reading the above and understanding my rights as outlined, please be advised that:
I do not desire a pre-termination hearing on the above charges, and I hereby waive my right to said hearing. I
understand that I will be notified if any disciplinary action is taken against me.
I will attend the pre-termination hearing regarding the above stated incident(s).
____________________________________ Best Phone Number: ______________________________
Employee Signature and Date Email: __________________________________________