Policy Manual sample

MDT Home Health Care Agency, Inc. HOME HEALTH CARE AGENCY INAPPROPRIATE BEHAVIOR DOCUMENTATION To: (Employee with inappropriate behavior)_________________________________ From: (Employee’s immediate supervisor)____________________________________ Date: _________________________ Subject: Inappropriate behavior This is to provide documentation of our _______ (Date) discussion regarding your inappropriate behavior, apparently demonstrated, as follows: ! Individuals present during our discussions:_____________________________ ! Reason for our discussion was to give you information about how other individuals perceive your behavior and to give you a: __ formal counseling session __ verbal warning notice __ written warning notice __ suspension notice __ termination notice ! Description of documented inappropriate behavior you apparently demonstrated: _______________________________________________________ ! Summary of discussion issues from: ________________________________ __________________________________________________________________ ! your perspective_________________________________________________ ! management perspective__________________________________________ ! Plan of corrective action will be as follows:___________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ you will be expected to: ___________________________________________________________________ The consequences for you if you do not meet the defined expectations and if you demonstrate any further inappropriate behaviors will be: __________________________________________________________________________ __________________________________________________________ Please be informed that all documentation related to your inappropriate behavior will be placed in your personnel file. Please contact me if I can be of any assistance to you or if you have any question and/or concerns. _____________________________________ ________________ Signature of Employee’s Immediate Supervisor Date Home Health Agency. - - Personnel/Operations Policies B-63