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NCWVCAA Incident Report Form

This document is a corrective action form for an employee of the NCWVCAA. It records the nature of an incident, including the employee's position, location, date and time. Facts of the incident and witness statements can be attached. The employee is allowed to provide comments. Depending on the severity, actions like warnings, suspensions, performance plans or termination may be taken. The action and timeline must be reviewed and signed by the employee, supervisor, program director, and possibly executive director. A copy is kept on file.

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291 views4 pages

NCWVCAA Incident Report Form

This document is a corrective action form for an employee of the NCWVCAA. It records the nature of an incident, including the employee's position, location, date and time. Facts of the incident and witness statements can be attached. The employee is allowed to provide comments. Depending on the severity, actions like warnings, suspensions, performance plans or termination may be taken. The action and timeline must be reviewed and signed by the employee, supervisor, program director, and possibly executive director. A copy is kept on file.

Uploaded by

Reyndi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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NCWVCAA CORRECTIVE ACTION

Name:
Position:
Location of Incident:

Program:
County:

Supervisor:
Date of Incident:
Time of Incident:

NATURE OF INCIDENT
Please choose from drop down box:

(This list contains a small sampling of instances that do or may require corrective action and is not intended to be all encompassi

Instance:
Instance:
Instance:
Instance:
Instance:
Other:

Facts of Incident (attach additional information if necessary):

Witnesses:
Employee's Comments (attach additional information if necessary):

Depending upon the severity of non-compliance, the following options may be administered in a progressive fashion or at any level de

appropriate by the supervisor. NCWVCAA's policies are not intended to limit, in any way, the employer's right to terminate an employ
any time, with or without cause, or with or without advanced notice.

ACTION TAKEN
Please choose from drop down box:

Warning:
Suspension:
Performance Improvement Plan provided:
Timetable of Improvement:
Consequences of Failure to Improve:
Supervisor:

Other:

Date:

I HAVE READ THIS REPORT:


Employee:
Program Director:
Human Resources:
Executive Director (If termination requested)

Date:
Date:
Date:
Date

Copy to:

Employee

Supervisor

Program Director

Revised: 8/1

ll encompassing)

at any level deemed

ate an employee at

vised: 8/12adp

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