Employee write-up form (disciplinary action form)

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.

Use this template

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Employee’s name (required)

Job title (required)

Department

Employee’s work email

So HR can write to them about this notice.

Supervisor issuing this notice (required)

Date of this notice (required)

What happened

Type of issue (required)

Choose as many as you like

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.

24 questions · about 8 min · logic · file upload · signature

No sign-up to start
Unlimited responses on Free

Print it as a PDF Word version

Change the questions in Word, then print.

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
Employee’s work email: jordan.ellis@example.com
Supervisor issuing this notice: Nina Kowalski
Date of this notice: 18 Sep 2026

and 8 more answers

A sample email with made-up answers.

submitted_at	Employee’s name	Job title	Department	Employee’s work email	Supervisor issuing this notice
23 Sep 2026 09:41	Jordan Ellis	Warehouse operator	Dispatch	jordan.ellis@example.com	Nina Kowalski

Export to CSV or Excel, or send responses to Google Sheets, Notion, Airtable, Slack or a webhook. All free.

What happens after someone submits

The supervisor saves the notice in the meeting. What happens next is set up once, in the Workflows tab.

Submitted
The notice is saved

HR gets an email with a PDF of the signed notice attached, ready for the employee’s file.
The action is a suspension

Payroll gets its own email with the suspension dates and whether it is paid.
HR follows up with the employee

HR writes to the employee from the record, and their answer, such as an appeal, lands in the same thread.

Set this up when you use the template

What this form asks, and why

The last column shows how often real disciplinary action forms ask for it.

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
Employee’s work email	Optional. Lets HR write to the employee from the record.	Our own recommendation
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.	12 of 18 forms
Policy or rule involved	Required after “Breach of policy”: the rule itself. 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	Every form has it. It asks for facts, 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 cannot block the record.	18 of 18 forms
For the supervisor	Checked 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	Someone who saw the notice handed over.	3 of 18 forms

What we left out

A threat for refusing to sign. One county threatens “immediate termination”. Ours records the refusal and a witness.
An HR sign-off line. On 10 of 18 forms and our PDF. Online, the notice goes to HR by email.
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

How many include each field, from forms organizations use today. Part of the Form Field Index.

Employee's signature line 18 of 18
Free-text description of what happened 18 of 18
Supervisor or manager signature 18 of 18
The employee's name 18 of 18
Date beside the signature 17 of 18
Level of action 17 of 18
Improvement plan 16 of 18
The date of the notice / form 14 of 18

Read September 2026 · US 17, Canada 1 · Sources

Washington College · college, US
Alliant Outsourcing · HR and payroll outsourcing firm, US
Bastrop County, Texas · county government, US
City of Bowling Green, Ohio · city government, US
Kansas State University · university, US
South Island Division of Family Practice · nonprofit (physician network), Canada
Helpside · PEO (HR outsourcing firm), US
Alfred University · university, US
Kean University · university, US
City of Springfield, Oregon · city government, US
State Security Agency · security services company, US
Heart City Health Center · community health center, US
Grand Forks Park District · park district, US
Western University of Health Sciences · university, US
EESI (Employer Solutions) · PEO (HR outsourcing firm), US
StaffScapes · PEO (HR outsourcing firm), US
FRM (PEO, Sarasota, Florida) · PEO (HR outsourcing firm), US
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.

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

shows “Earlier conversations or warnings”
When “Action being taken” is “Suspension”

shows “Suspension starts”, “Last day of the suspension” and “Is the suspension paid?”
When “Action being taken” is “Termination”

shows “Record the end of employment on the employee termination form”
When “Action being taken” is not “Termination”

shows “What needs to change, and by when”, “Review date” and “If things do not improve, further action may follow, up to and…”
When “For the supervisor” is checked

shows “Witness’s name”
When “Action being taken” is “Termination”

shows the “Now record the termination” ending

Make it yours

Keep it to managers

Turn on Password protection in Settings → Access and limits, and share it with people who issue warnings.
Finish it in the meeting

Save respondents’ progress on their device (Settings → Responses) is on, so a half-done record reopens there.
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.

Everywhere
Before the meeting, check the facts, and check that the action matches what others got for the same thing. In the meeting, explain the problem, show the evidence, and let the employee answer each point. Then decide, finish this record while it is fresh, and give the employee the decision in writing, with how to appeal and when you will review progress. Acas, disciplinary procedure step by step
US
Discipline decisions may not take race, color, 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; the UK preset records it. 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?

Check “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?

Not quite the job? One of these may fit, or browse all HR and employee forms.

Employee separation form
When the job is ending: final pay, property and access.
Near miss report form
For an accident, injury or near miss, where nobody is being disciplined.
Absence report
For one absence as it happens, before it becomes a pattern.

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.