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DISCHARGE SUMMARY Print Employee Name ______Emp # ______

Job Title ______Dept Name ______

Print Manager Name ______Date of Infraction ______/______/______

Introductory Period Employee? YES NO Discharge Reason : (ENTER CODE HERE) ______

ATT Attendance FPP Failed Introductory Period GMC Gross Misconduct HIP HIPAA Violation JOB Job Abandonment VIO Rules Violation PER Performance SAF Safety Violation  If applicable, list dates and type (Coaching Memo or PIP) of previous coaching and counseling prior to discharge:

 Specific description of infraction(s) or area(s) for improvement (If reason is attendance, list date and reason given by employee for unscheduled absence (full or partial), start/end of scheduled shift and arrival time/time left work for a partial absence, start of scheduled shift and arrival time for tardy, and/or time called in for late call)(If reason is not attendance, list date, specific description of incident(s), and the employee’s response to the incident(s)):

 What specific policy, rule, or guideline did the employee violate?

Have all the appropriate leaders been advised of and approved this discharge? ______ Please forward this and all related documentation to Employee Relations, Human Resources. ______Signature: Manager Date ______Signature: Witness (if applicable) Date

 Concluding the discharge, if the employee is beyond his/her initial introductory period and is eligible to file a discharge dispute request, please advise the employee of his/her right to file it with HR within five business days.  Immediately, submit an automated EIF using the Discharge Reason listed above. cc. Employee, Manager’s File, Employee Relations, Human Resources DISCHARGE SUMMARY- MANAGER REFERENCE TOOL FOR MANAGER USE ONLY – NOT FOR DISTRIBUTION TO EMPLOYEE

CODE REASON EXAMPLES OF BEHAVIORS  UNSCHEDULED ABSENCES-FULL OR PARTIAL  TARDINESS ATT ATTENDANCE  LATE CALL  FAILURE TO CLOCK IN/OUT  NO CALL, NO SHOW  EMP TERMED IN FIRST SIX MONTHS OF FPP FAILED INTRODUCTORY PERIOD EMPLOYMENT WITH MCGHI OR IN FIRST SIX MONTHS OF TRANSFER INTO A NEW POSITION  THEFT, UNAUTHORIZED USE, DEFACEMENT, OR WILLFUL DESTRUCTION OF PROPERTY  DISCRIMINATION/ HARASSMENT/RETALIATION GMC GROSS MISCONDUCT  WORKPLACE VIOLENCE  SUBSTANCE ABUSE VIOLATIONS OR DRUG OFFENSES  HIPAA VIOLATIONS - HR & COMPLIANCE HIP HIPAA VIOLATION CONSULT REQUIRED  PATIENT ID ERRORS  MEDICATION ERRORS SAFETY VIOLATION  MISLABELED SPECIMENS SAF  HAZARDOUS ACTIVITIES  ANY OTHER VIOLATION THAT WOULD CAUSE A PATIENT SAFETY CONCERN  EMP DOES NOT MEET REQUIREMENTS TO PERFORM JOB  ERRORS PER PERFORMANCE  INACCURACIES  CAN NOT MEET PRODUCTIVITY STANDARDS (NOT BEHAVIORAL ISSUES)  INAPPROPRIATE TREATMENT OF NEGLECT OF A PATIENT  FALSIFICATION OF DOCUMENTS/RECORDS  INSUBORDINATION/WILLFUL DISOBEDIENCE  SLEEPING ON JOB/FAILURE TO MAINTAIN A PERSONAL, MENTAL, OR PHYSICAL CONDITION AT STANDARD VIO RULES VIOLATION  INAPPROPRIATE SHARING CONFIDENTIAL INFO (NOT HIPAA VIOLATION)  EXPLOITATION OF PATIENTS OR FAMILIES FOR PERSONAL GAIN OR BENEFIT  RUDE OR DISCOURTEOUS CONDUCT TOWARD PATIENTS/EMPLOYEES/VISITORS  EMP VIOLATES A SPECIFIC RULE OR POLICY OR DEPT PRACTICE This list contains examples of actions that would fall under each code; however it is not all inclusive. Should you have any questions or concerns in completing this form, please contact Employee Relations, Human Resources.