City of Miami

        RECORD OF FORMAL COUNSELING

Employee Name:      

Date of Counseling:     

Social Security No:      

Department:      

PERFORMANCE OR CONDUCT DISCUSSED

 Attendance

 Lateness/Early Quit

 Rudeness to Employee/Citizens

 Unsatisfactory Work Quality

 Carelessness

 Failure to Follow Instructions

 Damage to Material/Equipment

 Violation of City Policies/or Procedures

 Insubordination

 Violation of Safety Rules

 Working on personal Maters

 Other

SUPERVISOR STATEMENT

EMPLOYEE COMMENTS

Date of Incident:      

Time:      

 Agree

 Disagree with Supervisor’s statement

Objections:      

Employee Signature:

Date:

CORRECTIVE ACTION TO BE TAKEN

POSSIBLE CONSEQUENCES SHOULD INCIDENT OCCUR AGAIN

I have read this Record of Formal Counseling and Understand it.

Signature of Employee

Date

Signature of supervisor Who Issued Counseling Notice

Date

C

CM/LR-129 Rev Dec. 2000