Employee Counseling Form

Today's Date(Required)

Date of the incident or issue of concern.(Required)

This could be several dates, but put the first date it happened.

Employee Name:(Required)

First and Last or initials Example: John Anderson or JA

Who ask you to fill out this form?(Required)

Name or initials

Please describe the incident or reason for filling out this form:(Required)

This is for my employee review or I was late to work on 11/21/2025.

Please describe three things that did not go well(Required)

Example: The truck was damaged on the bumper. The wreck is going to cost money. I was late to the appointment. Dispatch had to adjust the schedule with short notice.

Please Describe three things that went well:(Required)

Example: The wreck was deemed not my fault. I learned that my actions were responsible for this accident. I prevented the truck fire by following the policies.

Only If Necessary: What could have been done, by you or someone else, to prevent this incident/issue?

Example: I should have submitted my paperwork on time, I could have gotten out of the truck and looked, or gloves would have protected my hands from the cut.

Please check the appropriate response for your acknowledgment that this form is being used to gather information and record this information for future use. All data will be reviewed and a response may be added by a manager. In some cases you will not receive the managers response.(Required)

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