Clinical Supervisor Written Performance Counseling Form

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CLINICAL SUPERVISOR WRITTEN PERFORMANCE COUNSELING FORM

Phone: (248) 395-3777, Fax: (248) 395-3370, www.hchs.com, 28000 Woodward Ave., Ste 100., Royal Oak, MI 48067

The purpose of this form is to provide information to the Human Resources Department, in a standardized manner, regarding potential disciplinary actions (DAs) that may be needed. Providing as much factual information as possible in this form will allow the Human Resources Department to complete and execute DAs in a timely manner.

Employee First Name *

Employee Last Name *

Discipline: *

Type of violation/concern: (check all that apply) *

Safety

Attendance

Attendance - No Call No Show

Falsification of Time and/or Clinical Records

Breach of Professional Boundaries

HIPAA Violation

Violation of Job Description

If Safety: (please select)

Clinical

Non-Clinical

Date(s) of occurrence: * 🛈

Time Period: *

Shift Time: *

Number of Tardies: *

Number of Call Offs: *

The relevant facts are as follows: *

Additional Information (If no additional information, type N/A): *

Policies and Procedures violated? * 🛈

Was a complaint initiated? *

Yes

No

If no, should the Compliance & Experience Officer be notified regarding this issue? *

Yes

No

Please attach any relevant documentation you may have below:

Document 1

Document 2

Document 3

Document 4

First Name of Employee Submitting Report: *

Last Name of Employee Submitting Report: *

Discipline: *

Date: * +

v1 - 04.01.18