Statement of Purpose

The Corrective Action Reporting Form is intended for use by Human Resources to easily document and maintain a database of corrective action incidents and the administration of performance improvement plans. See HR Policy 5250

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Items marked with a diamond ♦ are required fields.

Submitted By (You, HR Staff, entering this report)

	Save “Your Name & Contact Information” for future use. (By checking this box you agree to allow NAVEX Global to store your information in a “Cookie” on this computer.)

Your Name & Contact Information	Prefix (Select One) ♦ First Name M.I. ♦ Last Name ♦ Position Title Employee ID Phone Number (Preferred) Include the area code, extension, and/or dialing codes if applicable. Phone Number (Alternative) Include the area code, extension, and/or dialing codes if applicable. Email (Format: username@domain.com)

Reason for Corrective Action

Employee (The employee receiving corrective action)

Employee Name & Contact Information	Prefix (Select One) ♦ First Name M.I. ♦ Last Name ♦ Position Title Position Level Date Service (Format: mm/dd/yyyy) ♦ Department or Division ♦ Employee ID Employee Status (Select One) Phone Number (Preferred) Include the area code, extension, and/or dialing codes if applicable. Phone Number (Alternative) Include the area code, extension, and/or dialing codes if applicable. Email (Format: username@domain.com)

Employee Name &
Contact Information

Prefix

(Select One)

♦

First Name

M.I.

♦

Last Name

♦

Position Title

Position Level

Date Service

(Format: mm/dd/yyyy)

♦

Department or Division

♦

Employee ID

Employee Status

(Select One)

Phone Number (Preferred)

Include the area code, extension,
and/or dialing codes if applicable.

Phone Number (Alternative)

Include the area code, extension,
and/or dialing codes if applicable.

(Format: username@domain.com)

Supervisor/Manager

Supervisor Name & Contact Information	Prefix (Select One) ♦ First Name M.I. ♦ Last Name ♦ Position Title Employee ID Phone Number (Preferred) Include the area code, extension, and/or dialing codes if applicable. Phone Number (Alternative) Include the area code, extension, and/or dialing codes if applicable. Email (Format: username@domain.com)

Location

Location

Incident Details

Dates	♦ Date of Discussion (Format: mm/dd/yyyy) ♦ Date of Incident (Format: mm/dd/yyyy)

Actions	♦ Action Taken Select One Secondary Action Taken Select One Other Action Taken Select One

Details	♦ Summary

File Upload

File Upload	Here you can upload files and documents for the company to review that are related to this report. Select a file File Description Files Uploaded: Space Remaining: Max File Size: Errors:

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HR Corrective Action Reporting Form

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