Staffing Ratio Violations

Staffing Ratio Violations

Report and document staffing discrepancies or concerns

Did you follow these steps before filling out this form?

Reported violations of the contract or concerns about staffing in the following order when it was assigned to:

If violations were not resolved, document on this form whom you spoke with.

Contacted your union representative.

Unit Staffing Information

Help us document and track staffing on your unit.
Select your Site and Unit. If you are submitting the form for multiple units select other in the unit drop-down. Add the department names in the comments area.*
Shift*
Date*

MonthDayYear
Date

Please provide the total number for each group if you have them available.

	Patient Census	Number of PCTs	Number of Sitters	Number of RNs	Number of RNs Floated	Number of RNs Callouts
totals

Concern/Violation

Please refer to Article XXXII of the collective bargaining agreement (see bottom of this form) for staffing ratio of your department.
Select all violations that apply*
Select other concerns

Contact Information