ASSIGNMENT DESPITE OBJECTION
Report an incident or ongoing concern about workload or staffing that impacts quality of patient care or quality of work life at KSMC or KWMC. This form is not HIPAA approved. Please do not submit PHI.
INCIDENT INFORMATION
Date of Incident
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/
Month
/
Day
Year
Date
My assignment was unsafe because:
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Not staffed to RN Matrix
Not staffed to support staff matrix/shorted ancillary staff CNA, Tech, RT, Rehab, etc
Not staffed to patient acuity
Charge forced to take an assignment beyond two hours
Equipment and resource issues
Manager performed work usually done by a staff member
Not oriented to unit
Did you ask for additional staff?
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Yes, support staff (CNA, Transport/Mobility, RT, Rehab, etc)
Yes, RN
No, I did not ask.
Did you receive requested staff?
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Yes
No
Other
Which bargaining unit are you in?
RN
Pro
Tech
Lab Pro
Other Details
Did your concerns lead to a violation of your right to uninterrupted rest or meal breaks?
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Please Select
yes
no
Did you work overtime?
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Yes, I volunteered.
Yes, I was mandated.
No, I did not.
Did this incident explicitly violate your approved hospital staffing plan?
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Yes
No
Unsure / My department isn't covered by the hospital staffing plan
INCIDENT NARRATIVE
Type narrative here
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Name
*
Email
*
example@example.com
Hospital
*
Please Select
Kaiser Westside Medical Center
Kaiser Sunnyside Medical Center
Arena
*
Please Select
KWMC Critical Care
KWMC Emergency
KWMC MCWH
KWMC Respiratory Therapy
KWMC Med-Surg
KWMC Surgical Services
KWMC Rehab
Arena
*
Please Select
KSMC Emergency
KSMC Critical Care
KSMC Med-Surg
KSMC MCWH
KSMC Surgical Services
KSMC Rehab
KSMC Care Management
Dept/Unit
Shift
Supervisor/Manager's Name
Supervisor/Manager's Email
example@example.com
Submit
Should be Empty: