• Staffing Ratio Violations

    Report and document staffing discrepancies or concerns

  • Did you follow these steps before filling out this form?

    1

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

    • Charge Nurse
    • ANM
    • Nurse Manager

     If violations were not resolved, document on this form whom you spoke with.
    2  Contacted your union representative.

     

  • Contact Information

  • Format: (000) 000-0000.

  • 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.*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Please provide the total number for each group if you have them available.
    Rows

  • 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
  • Please provide any nurses, including yourself, that are over ratio and the total number of patients per nurse. If you do not feel comfortable providing a name use the person's title. If you need more rows click on the Add Nurse button bellow.
  • To whom did you report the staffing discrepancies? Please provide the title and the name. If you need more rows click on the Add Administrator button bellow.
  • Image field 34
  • 0/1000
  • Unit had HUS
  • (Select all that apply.)
  • Charge nurse had patients*
  • Should be Empty: