FAX (916) 503-6917 suPeRvisoR’s RePoRt (RefeRRal)
Employee’s Name
Company
Department
Type of Work
Date Hired
Age :
Sex: M o F o
Reason for Referral:
PeRfoRmance PRoblems
1)
o
o
o
Quality:
Misses deadlines
Details neglected Work differs in quality
2) Quantity:
o Lowered Output
o Undependable
oJob takes more time
Comments:
o Poor decisions
oDependent on others
o Unable to keep current
oOther:
o Frequent Mistakes
o High/low productivity periods
oDifficulty in handling complex assignments
oOther:
3) Absenteeism/Tardiness:
o Unauthorized leave
oRepeated absence of 1-2 days
oImprobable excuses
oExcessive sick leave
o Repeated absence of 1-2 weeks
o Frequent, unscheduled absences
o Monday/Friday absence
o Late returning from lunch
o Leaving work early
o Late returning from breaks
o Late coming to work on time
o Higher rate of illness than
other employees
Days Absent (Specific Dates) ___________________________ Days Late (Specific Dates)
Days Left Early(Specific Dates)
oOther:
4) Initiative:
oUnwilling to change work responsibilities
o Unwilling to change ways
o Needs constant supervision of doing job
oOther:
(Over)
5) Interpersonal:
o Over-reacts to real or imagined criticism
o Wide swings in morale
oConstant complaints to co-workers/supervisors
oCustomer complaints
o Overly critical of others
o Makes unreliable or untrue statements
oOther: ____________________________________________________________________________________
6) Abnormal behavior:
o Coming to or returning to work in an obviously abnormal condition
oObviously bizarre or abnormal actions on the job
o Makes threats of violence, exhibits weapons, talks about doing harm to others
Comments: ___________________________________________________________________________________
7) Appearance (indicate recent changes):
oUnkempt or unclean
o Disheveled appearance oOther: ____________________________________________________________________________________
8) Attitude (indicate recent changes):
o Toward supervisor
o Toward others: _________________________________________
oOther: ____________________________________________________________________________________
9) On-duty accidents:
oAccidents to equipment
o Accidents off the job but affecting work performance
oAccidents on the job
o Frequent trips to Occupational/Employee Health
oOther: ____________________________________________________________________________________
Personal problems:
o Interfering with work
o Concerned for employee
Comments: ______________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________
Warnings or disciplinary actions taken (Nature, Dates):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Supervisor’s observations (Including attempts at correction and summary of last meeting):
________________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
______________________________________________________________
_____________________
____________________________________________________________________________
Job title
__________________________
supervisor’s Phone number
supervisor’s name (Please Print)
Date