Pre-Disciplinary Form

Email to – Aleta Sanford – Divisions aleta.sanford@nebraska.gov

Millie Washington - D1-D3 millie.washington@nebraska.gov

Jessica Kreger – D4-D8 jessica.kreger@nebraska.gov

1.	PLEASE NOTE: If the employee has requested or been approved for FMLA leave, or has sought or been provided leave/accommodation for an ongoing condition, please contact HR prior to completing this form so that we may better understand the circumstances regarding this employee.

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2.	Date: Enter date

Employee’s Name and Title: Enter text

Supervisor’s Name and Title:	Enter text

Pre-Dis – FROM (Name/title):	Enter text

Pre-Dis –THRU (Name/Title):	Enter text

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3.	Describe situation – Please be specific – Times, dates, names, locations (EX: On 5/4/23 at approximately 2:00 p.m., Bo Gator was backing up his State truck and hit another vehicle causing damage to the front panel and passenger door.)

Enter text

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4.	Describe what policy, procedure, or guidance that was not followed - Please be specific (Example: It is District policy that no trucks are to be backed up without using a spotter when available. Bo Gator did not utilize an available spotter as required.)

Enter text

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5.	Is Employee on Original Probation:	Yes	Date ending:

No

Extended Probation:	Yes	Date ending:

No

Disciplinary Probation:	Yes	Date ending:

No

Promotional Probation:	Yes	Date ending:

No	__________________________

6.	Pre-disciplinary Meeting with Employee – Document meeting information here.

Enter text

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7.	Chain of Command Notified of Pending Disciplinary Action

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Section below is to be determined AFTER meeting with Employee

8.	Disciplinary Action Requested:

No Disciplinary Warranted

Documented Verbal Counseling – (will not go in employee’s HR file)

Comments:	Enter text

Written Warning

Comments:	Enter text

Disciplinary Probation – [please indicate length of extension (6 mo.) below]

Enter text

Leave Without Pay – (indicate number of days below)

Enter text

Termination:

Effective Date:	Enter date

Other:

Explain:	Enter text