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Sample Forms and Acknowledgments


Employers often include provisions in their personnel manuals advising employees that policies may be changed at any time, as well as a form for the employee to sign acknowledging receipt of the policies.  Following are samples of these provisions:

      Amendment of Policies

It is the responsibility of all employees to carry out and comply with the rules and regulations contained in this manual. The employee should be aware that these rules and regulations are subject to periodic review and change by the employer. Before relying upon the provisions set out herein, it is the employee’s responsibility to check with the employer to see if any changes have occurred.

Sample Employee Acknowledgment Form - Receipt of Policies

EMPLOYEE ACKNOWLEDGMENT [two copies — give one to the employee and place the other copy in the employee’s personnel file]

By signing this form, I acknowledge that I have received a copy of the personnel policies currently in effect for my office as of this date, and I understand that it is my responsibility to read and comply with the policies.

These policies cannot and are not intended to answer every question about my employment with ______________ County. I understand that I should consult [county official] regarding any part of the policies that I do not understand or any questions I may have about my employment with ________________ County that are not answered in the policies. The current policies will always be on file in the office of the County Clerk, and I may examine them there at any time during normal business hours.

The policies are necessarily subject to change, and I acknowledge that revisions may occur from time to time. I understand that all changes to the policies will be filed in the office of the County Clerk. Although my employer will usually provide me with notice of changes, I understand that changes will apply to me regardless of whether I receive actual notice. I understand that revised information may supercede, modify or eliminate any or all of the policies at any time. All information contained in the policies is subject to applicable state and federal laws, rules and regulations, and I understand that to the extent that any such laws may conflict with any provision of the policies, such laws, rules and regulations will control.

I have entered into my employment relationship with ___________ County voluntarily, and I acknowledge that there is no specific length of employment and that my employment may be terminated by me or by my employer at will, without cause or prior notice, at any time.

I acknowledge that none of the ___________ County’s policies may be construed to create a contract of employment or any other legal obligation, express or implied, and that any policy may be amended, revised, supplemented, rescinded or otherwise altered, in whole or in part, at any time, in the sole and absolute discretion of ___________ County.

Employee Name (type or print)

_____________________________ ________________
Employee Signature Date


Notice Regarding Falsification of Governmental Records.  A copy of Tennessee Code Annotated § 39-16-504 is required to be furnished to all employees under T.C.A. § 5-23-107, and should be included in all personnel manuals.  The statutory language is as follows:

T.C.A. § 39-16-504. Government record; destruction, tampering or fabrication.

(a) It is unlawful for any person to:

  1. Knowingly make a false entry in, or false alteration of, a governmental record;
  2. Make, present, or use any record, document or thing with knowledge of its falsity and with intent that it will be taken as a genuine governmental record; or
  3. Intentionally and unlawfully destroy, conceal, remove or otherwise impair the verity, legibility or availability of a governmental record.

(b) A violation of this section is a Class E felony.