PRE-DISCIPLINARYCONFERENCENOTIFICATION LETTER AND REPORT

** (Use only for Dismissal, Demotion, or Suspension) **

DATE:
TO:
Employee Name / Job Title / EOD
Employee EID / Department Name
FROM:
Supervisor/Manager Name

You are being issued this Pre-Disciplinary Conference Notification Letter to advise you that your Pre-Disciplinary Conference is scheduled for (Date)_____ at____ (am/pm) in the following location

The purpose of the conference is to allow you the opportunity to present any facts verbally or in writing about your current unresolved incident,described below, that you believe support your case and are relative to the proposed disciplinary action. You may provide any factual information that you would like management to consider prior to making a decision to take the possible disciplinary action of Dismissal, Demotion, or Suspension w/o Pay (Circle one)with UNC Health Care.

The Just Culture Algorithm has been used for guidance.Disciplinary action in the form ofDismissal,
Demotion, orSuspension w/o Pay (check one) has been proposed for the following reason (check only one reason):

__Unacceptable personal conduct

__Unsatisfactory job performance

When a Dismissal, Demotion or Suspension without pay is proposed the Just Culture Algorithm must be used for guidance. Please initial here to indicate this has occurred_____.

You have a current unresolved incident and the facts of the incident which management believes supports the proposed disciplinary action are as follows:

(Write the facts of the current,unresolved incident here. Use the "first person" narrative, i.e. "I observed you…I am proposing your dismissal for the following reasons: etc." Be specific with dates, times, event details, circumstances, etc. Tell the "story" of what the employee did that was poor job performance or poor conduct. Include the information the employee provided you when you questioned the employee when learning of the poor performance/conduct issue(s). Include witness reports also, if any, and include any rules, policies, procedures, and processes that were violated and the negative consequences and/or risk the poor performance/conduct caused to patients, co-workers, the department, and/or organization.)

I, the employee, have read the information above about this proposed disciplinary action and understand the recommendation for disciplinary action. I understand that no attorneys are allowed to represent me or UNC Health Care at this conference and no witnesses will be allowed to present facts at this conference.

I, the employee, understand that I may submit written information at the time of my conference that supports my case and I am also expected to verbally present facts that I believe support my case to avoid this potential, proposed disciplinary action. I understand that if I fail to appear at this scheduled Pre-disciplinary Conference, my failure to appear will be considered a Voluntary Resignation without Notice.

In addition, I, the employee, understand that if I have previous corrective actions on file these corrective actions will not be discussed in this disciplinary action conference. Previous corrective actions are listed below for historical reference only and are as follows:

(List dates and types of counseling and corrective actions on file or state “non-applicable” if there are no previous counselings/corrective actions.)

Date / Types of counseling and corrective actions on file

Any proposed disciplinary action to be taken will be discussed with and receive the approval of your Departmental Manager, Division Executive, and UNC Health Care Director of Employee Relations, or his/her designee.

I, the employee, understand that if this conference results in dismissal, demotion or suspension without pay, it is within my rights to grieve this action. Attached to this report please find a copy of the UNC Health Care Grievance Resolution policy.

Please be advised: If this conference results in your dismissal, NCGS § 126-23 (a) (11) provides that dismissal letters are public information and must be released if requested.

______

Employee Signature Supervisor Signature / Title

If employee refuses to sign:

______OR  Sent Certified Mail

Signature of Witness

Attachments: UNC Health Care Employee Grievance Resolution policy

Cc:HRDMRecords

Employee’s Departmental Personnel file

Division Director