Preliminary Conduct Review Form Instructions

Please provide the printed full name of the conduct assessor.

Please provide the job title of the conduct assessor.

Enter the signature of the conduct assessor.

Enter the date of the conduct assessor's signature.

Provide the printed full name of the conduct investigator.

Provide the job title of the conduct investigator.

Provide the signature of the conduct investigator.

Provide the date the conduct investigator signed.

Enter the printed name of the conduct official.

Enter the job title of the conduct official.

Enter the signature of the Conduct Official.

Enter the date of the Conduct Official's signature.

Check this box if a conduct review is warranted for the alleged violation number(s).

Enter the alleged violation number(s) for which a conduct review is warranted. Fill only if 'Conduct review warranted' is 'Yes'.

Check this box if a conduct review is not warranted and no further action is needed.

Check this box if a conduct review is not warranted and the case should be returned to the conduct assessor for Progressive Corrective Action (PCA).

Please enter the full printed name of the employee.

Please enter the Pavee ID number for the employee.

Please enter the job title of the employee.

Please enter the unit or division of the employee.

Check this box if the employee's statement is attached to this form.

Check this box if the employee refused to provide a statement.

Please provide the identifying number for the first alleged violation.

Please enter the title or a brief description of the first alleged violation.

Please enter the date when the first alleged violation incident occurred.

Provide a detailed description of the incident, including any high-level investigations or findings if applicable.

Provide a detailed explanation of how the behavior or incident affected the agency.

Check this box if the investigator recommends that a conduct review should be initiated.

Check this box if the investigator recommends that a conduct review should not be initiated.

Please provide the alleged violation number or numbers.

Please provide any additional comments or observations regarding the conduct review.

Check this box if the preliminary conduct review was delayed.

Please enter the number of days the preliminary conduct review was delayed. Fill only if 'Preliminary Conduct Review Delayed' is 'Yes'.

Please provide the reason for the delay in the preliminary conduct review. Fill only if 'Preliminary Conduct Review Delayed' is 'Yes'.

Check this box if the unacceptable performance or misconduct was previously addressed through counseling, and PERS 181 is attached.

Check this box if the unacceptable performance or misconduct was previously addressed through an Employee Development Plan, and PERS 182 is attached.

Check this box if the unacceptable performance or misconduct has not been previously addressed through progressive corrective action.

Provide a detailed justification for why unacceptable performance or misconduct has not been previously addressed through progressive corrective action. Fill only if 'No' is 'Yes'.

Provide the number for the second alleged violation.

Enter the title for the second alleged violation.

Provide the date of the second alleged incident.

Provide the email address for contact.

Provide the phone number for contact.

Indicate the preferred time to be called. Fill only if is 'Yes'.

Provide the full mailing address for contact.

Provide the names and details of any witnesses who will provide statements on behalf of the conduct assessor.

Provide the names of individuals who are witnesses on behalf of the employee.