Policy Infraction

Policy Infraction Notice

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Employee Name *

Date

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Description of problem or Infraction

Previous discussions about the problem

Expected Performance Level

Actual Performance

Impact on business / Co-workers

Consequences

This discussion is intended to be:

Employee's Comments

Action necessary from coworkers / supervisor

Supervisor Name

Signature Date

Use AI Assist — click the AI Assist button on any field to help write clear, factual descriptions.
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Print / PDF — print a copy for the employee to sign.
Email to HR — send the completed notice to HR. Automatically removed from PBC after sending.

Heartland is the system of record — PBC is only used to fill out and deliver the notice.

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