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Disciplinary action form template

Write up a warning while the job continues: what happened, the action you are taking, what must change by when, and the employee’s response and signature.

23 questions · about 8 min · logic · file upload · e-signature

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Page 1 of 2

Employee’s name (required)

Job title (required)

Department

Supervisor issuing this notice (required)

Date of this notice (required)

What happened

Type of issue (required)

Policy or rule involved

For example “Mobile phone policy, section 3”.

Date of the incident (required)

The first date, if it happened more than once.

What happened (required)

Facts only: dates, times, who was there and the effect on the work. Describe conduct or performance, not the person.

Has this been raised with the employee before? (required)

Supporting documents

Click or drop a file here

PDF, images, Word · up to 10 MB

The action

Action being taken (required)

What needs to change, and by when (required)

Review date

When you will check progress together.

If things do not improve, further action may follow, up to and including dismissal.

Supervisor’s signature (required)

Draw your signature, or choose Type instead to type your name.

What you get back

Every response lands in your results the moment it is sent. Turn on email notifications and each one arrives like this, and the same answers become a row in your spreadsheet.

From PulseFormCreator

Subject New response to Disciplinary action notice

Employee’s name
Jordan Ellis
Job title
Warehouse operator
Department
Dispatch
Supervisor issuing this notice
Nina Kowalski
Date of this notice
2026-10-06
Type of issue
Attendance or lateness

and 8 more answers

A sample email with made-up answers.
submitted_atEmployee’s nameJob titleDepartmentSupervisor issuing this noticeDate of this notice
2026-09-22T09:41:00.000ZJordan EllisWarehouse operatorDispatchNina Kowalski2026-10-06

The first 6 of 40 columns. Export to CSV or Excel, or send each response to Google Sheets, Notion, Airtable, Slack or a webhook as it arrives, all on the free plan. The answers above are made up.

What this form asks, and why

The last column shows how many of the 18 real disciplinary action forms we read ask the same thing.

Question Why it is there Real forms
Employee’s name Required Whose record this is. 18 of 18 forms
Job title Required Ties the standard to the role, asked on 11 of 18 forms. 11 of 18 forms
Department Optional. Tells HR whose team it is. 6 of 18 forms
Supervisor issuing this notice Required Who is accountable for the action. 10 of 18 forms
Date of this notice Required Starts the clock on any review period. 14 of 18 forms
Type of issue Required A category checklist like 12 of 18 forms, so patterns show across records. 12 of 18 forms
Policy or rule involved Required after “Breach of policy”: the rule itself, not just the category. Only 5 of 18 forms ask. 5 of 18 forms
Date of the incident Required Kept apart from the notice date, which is often days later. 7 of 18 forms
What happened Required The one field every form has. The prompt asks for facts about conduct or performance, not opinions. 18 of 18 forms
Has this been raised with the employee before? Required Progressive discipline depends on the history. 10 of 18 forms
Earlier conversations or warnings Required Only when “Has this been raised with the employee before?” is Yes Shown after Yes: the record the next step relies on. 10 of 18 forms
Supporting documents Optional: examples, timesheets or the policy itself. Our own recommendation
Action being taken Required The level of action, recorded on 17 of 18 forms. 17 of 18 forms
Suspension starts Required Only when “Action being taken” is Suspension Shown only for a suspension. Payroll needs the dates. 4 of 18 forms
Last day of the suspension Required Only when “Action being taken” is Suspension The day before they return. 4 of 18 forms
Is the suspension paid? Required Only when “Action being taken” is Suspension Decides what payroll does. 4 of 18 forms
What needs to change, and by when Required Only when “Action being taken” is not Termination What must change and by when, on 16 of 18 forms. Hidden for a termination. 16 of 18 forms
Review date Only when “Action being taken” is not Termination Optional: when you will check progress. 7 of 18 forms
Supervisor’s signature Required Signed before the meeting ends. 18 of 18 forms
Your comments The employee’s side, which 13 of 18 forms make room for. 13 of 18 forms
Employee’s signature Optional, so a refusal does not block the record. The line above says it means receipt, not agreement. 18 of 18 forms
For the supervisor Ticked by the supervisor. 5 of 18 forms plan for a refusal. 5 of 18 forms
Witness’s name Required Only when “For the supervisor” is checked Shown after the tick: someone who saw the notice handed over. 3 of 18 forms

What we left out

  • A threat for refusing to sign. One county says refusal “will cause your immediate termination”. Ours records the refusal and a witness.
  • An HR sign-off line. On 10 of 18 forms. Send each record to HR by email instead, or add a second signature.
  • A termination date. 2 of 18 forms fold the end of employment in. It has its own record.

What 18 real disciplinary action forms ask

In September 2026 we read 18 disciplinary action forms that organisations use today (US 17, Canada 1) and recorded every field. This is how often each one appears. It is part of the Form Field Index.

  1. Employee's signature line 18 of 18 (18 of 18 forms)
  2. Free-text description of what happened 18 of 18 (18 of 18 forms)
  3. Supervisor or manager signature 18 of 18 (18 of 18 forms)
  4. The employee's name 18 of 18 (18 of 18 forms)
  5. Date beside the signature 17 of 18 (17 of 18 forms)
  6. Level of action 17 of 18 (17 of 18 forms)
  7. Improvement plan 16 of 18 (16 of 18 forms)
  8. The date of the notice / form 14 of 18 (14 of 18 forms)
  9. Employee’s statement 13 of 18 (13 of 18 forms)
  10. Says what happens next 13 of 18 (13 of 18 forms)
  11. Type of issue checklist 12 of 18 (12 of 18 forms)
  12. Says what signing means 11 of 18 (11 of 18 forms)
The 18 forms we read
  1. Washington College · college, US
  2. Alliant Outsourcing · HR and payroll outsourcing firm, US
  3. Bastrop County, Texas · county government, US
  4. City of Bowling Green, Ohio · city government, US
  5. Kansas State University · university, US
  6. South Island Division of Family Practice · nonprofit (physician network), Canada
  7. Helpside · PEO (HR outsourcing firm), US
  8. Alfred University · university, US
  9. Kean University · university, US
  10. City of Springfield, Oregon · city government, US
  11. State Security Agency · security services company, US
  12. Heart City Health Center · community health center, US
  13. Grand Forks Park District · park district, US
  14. Western University of Health Sciences · university, US
  15. EESI (Employer Solutions) · PEO (HR outsourcing firm), US
  16. StaffScapes · PEO (HR outsourcing firm), US
  17. FRM (PEO, Sarasota, Florida) · PEO (HR outsourcing firm), US
  18. ABC Equipment Rental (Tulsa, Oklahoma) · small business (equipment rental), US

How the form changes as people answer

Most people see a shorter form. These questions and screens only appear when an answer calls for them.

  1. When “Has this been raised with the employee before?” is Yes

    shows “Earlier conversations or warnings”

  2. When “Action being taken” is Suspension

    shows “Suspension starts”, “Last day of the suspension”, “Is the suspension paid?”

  3. When “Action being taken” is Termination

    shows “A note”

  4. When “Action being taken” is not Termination

    shows “What needs to change, and by when”, “Review date”, “A note”

  5. When “For the supervisor” is checked

    shows “Witness’s name”

  6. When “Action being taken” is Termination

    shows the “Now record the termination” ending

  7. At the end

    shows one of 2 thank-you screens: “Notice recorded for …”, “Now record the termination”

Make it yours

  1. Send every record to HR

    In the Connect tab, turn on email and put HR’s address in Also send to. It is free.

  2. Finish it in the meeting

    Save respondents’ progress on their device is on under Settings → Responses, so a half-done record reopens on the same device.

  3. Match your own ladder

    Edit the “Action being taken” options to your policy’s steps. Keep Termination, which ends on a pointer to the termination form.

Good practice and the law

This is general information, not legal advice. Rules differ by country and state, so check anything important where you operate.

  • US

    Discipline decisions may not take race, colour, religion, sex, national origin, age, disability or genetic information into account, or punish a complaint. EEOC, prohibited practices

  • UK

    Workers may bring a companion to a meeting that could end in a formal warning, and may appeal against any formal decision. The UK preset records the first and explains the second. Acas Code of Practice

Questions about this template

Is a disciplinary action form the same as a write-up?

Yes. “Write-up” is the everyday name for the same record: a documented warning the employee sees and signs.

Does signing a write-up mean the employee agrees?

No, and the form says so above the signature. 11 of 18 forms spell out what signing means, usually receipt rather than agreement.

What if the employee will not sign the warning?

Tick “The employee declined to sign” and name a witness. The record stands without the signature.

Can I use it for a verbal warning?

Pick “Coaching or verbal warning” above the preview: two levels of action and no employee signature.

Which form do you need?

The disciplinary action form is one of the hr & employee forms. If it is not quite the job, one of these may be.

Start with the disciplinary action form template

Open it in the editor, change the actions to match your policy, and fill it in before the meeting.

Use this template

Updated 22 September 2026. Evidence read September 2026 from 18 real forms.