08/05 PE47
CITY OF LITTLE ROCK
Human Resources Personnel File
Human Resources Disciplinary File
Department
Division
NON-UNIFORM EMPLOYEE
DISCIPLINARY ACTION FORM
RECORD OF SUSPENSION
DATE
EMPLOYEE #
DEPARTMENT
DIVISION
NUMBER OF DAYS
DATES OF SUSPENSION ____________________________
Employee Name
Complete Home Mailing Address
This is to advise you that you are hereby suspended for the following reasons:
You are hereby warned that a recurrence of this infraction, or other infractions, will result in further disciplinary
action up to and including termination.
You have the right to appeal this action and may request an administrative hearing within ten (10) working days
upon receipt of this letter.
/ /
Employee’s Signature Date Immediate Supervisor’s Signature Date
(Does not necessarily imply agreement with
the stated reasons and/or disciplinary action.)
OR (if applicable)
/ /
1. Witness Date Division Manager’s Signature Date
/ /
2. Witness Date Department Director’s Signature Date
(indicates review and approval)
/
Union Steward’s Signature Date
(if applicable)
