COUNSELING MEMORANDUM SAMPLE
James (Jay) E. Girvin, Esq.
20 Corporate Woods Boulevard
Albany, NY 12211
Telephone: 518-462-0300
Facsimile: 518-462-5037
jeg@
COUNSELING MEMORANDUM
SAMPLE
TO:
FROM:
DATE:
RE:
Memorandum of Counseling
1.
The following observation has been made:
?
2.
The following standards will be expected in the future:
?
3.
Set forth why the above was wrong (e.g. violated policy, failure to performance, etc.) and
what the specific expectations are for the future for the employee.
These standards/expectations are important because of the following impact on the school
environment:
?
4.
Set forth facts, incidents, and sufficient detail to describe the concern.
Set forth why the act/failure has a negative impact on the District, co-workers, residents,
morale of colleagues, etc.
Failure to follow the above standards/expectations will result in:
?
5.
e.g. additional counseling, forwarding the next matter to the Supervisor/Board for
consideration of discipline.
The [District] is available to assist you in the following manner:
?
Set forth how you or the District can help, e.g. offer to meet with and explain concerns,
offer list of courses of in-services that might improve the employee's performance, offer to
enter into a professional improvement plan.
Please sign and return this memorandum to _____________ within ______ days. Your signature
acknowledges that you have received a copy of this memorandum. You have the right to submit a written
response to this memorandum which, if submitted, will be attached to the memorandum.
I am forwarding this Memorandum of Counseling to the Supervisor/Clerk for inclusion in your
personnel file.
Sincerely,
I have read and received a copy of this Memorandum.
Employee
cc: Employee's Supervisor
[Other involved Administrators]
Personnel File
Date
James E. Girvin, Esq.
jeg@
COUNSELING MEMORANDUM LETTER
TO BE TYPED ON LETTERHEAD)
(Presented to Staff Member at a Meeting with Representative Present)
COUNSELING MEMORANDUM
TO:
FROM:
DATE:
RE:
INCIDENT OF: ____________
(Date)
On (date of meeting), you and I met to discuss an incident occurring on or about (date of incident).
Your union representative, (name) was also present. (or, you were offered the right to bring a union
representative, but declined).
On (date of incident), (I observed you or, you reportedly) (describe incident-who, what, when, where).
(I appreciate your honesty in admitting that the incident did occur as described above) (or) (your
version of the incident is __________). (State any prior notification, e.g. verbal warnings, memos, etc.
about this incident or any other incidents of a similar nature that may indicate a pattern of behavior)
Behavior of this type is improper because ____________________. (Make reference to Employee
Handbook, Administrative Regulation, District Policy, and Civil Service Law, etc.) There should be no
recurrence. If there is, you may be subjected to disciplinary sanctions, up to and including discharge, in
the manner provided for by law and/or the collective bargaining agreement.
In order to help you to avoid further problems of this nature, I am directing you to:
1.
2. ___________________________________
3. ___________________________________
Let me reiterate that the purpose of this Counseling Memorandum is to warn you of the serious
consequences of any future incident, and to instruct you as to how to avoid such problems in the future.
This Memorandum should not be construed as a formal accusation, charge, or formal disciplinary action
at this time. Formal disciplinary action based on the issue(s) addressed in this Counseling Memorandum
could take place in the future.
A copy of this Counseling Memorandum will be placed in your personnel file. If you wish to respond or
further clarify the situation in any way, you may submit a written response, which will also be placed in
your file as an attachment to this Memorandum.
Please sign this Counseling Memorandum where indicated below. Your signature serves as an
acknowledgment that you have had the opportunity to review the Memorandum, that you received a
copy, and that you are aware that a copy will be placed in your file. It does not necessarily indicate your
agreement with the contents.
If you have any questions, please feel free to contact me.
___________________
Date
_____________________________
Supervisor Administrator
Date
_____________________________
Employee Signature
................
................
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