Labcorp ADO

1
You are filing documentation of unsafe staffing and will generate a report that will go to only your union and not to management. This form is not HIPAA approved - Please do not provide PHI (confidential patient identifying information) in this form.* This field is required.
2
Are you employed by Labcorp?* This field is required.
Yes
No
3
Oops! It seems you've chosen the incorrect form. Please visit AFT.OFNHP.ORG to find the correct form.
4
Which type of issue would you like to report?* This field is required.
Staffing Issue
System Failure
Equipment Problem
Missed Break(s) and/or Lunch
Mandatory Overtime
Not Oriented to Unit
Suspected Unfair Labor Practices (or Illegal Anti-union Activity)
Suspected Ethical Violation
Issue With Testing
Other
5
What factors contributed to your staffing issue?* This field is required.
Insufficient staff on shift
Department staffed with untrained and/or unqualified personnel (e.g. orientation)
Patient intensity/workload is higher than planned
Unit activities are different than planned
Support staff different than planned
Inappropriate assignment for skill level
Lead unable to complete lead duties due to patient volume/acuity
Other
6
System Failure(s)* This field is required.
Computers
Lab Equipment
Medication bar coder
Call system
Other
7
Equipment Issue(s)* This field is required.
Equipment was unavailable
Equipment was substandard
Equipment was broken
I needed specialized equipment
I wasn't trained or experienced in the area assigned or to the equipment assigned
There was an issue with supplies
Other
8
Did you miss any breaks?* This field is required.
Meal Break 1
Meal Break 2
One rest break
Two rest breaks
Three or more rest breaks
Nope
9
Were you asked to work beyond your scheduled shift?* This field is required.
Yes, I volunteered to stay
Yes, I was required to stay
No, I wasn't
10
Did your issue compromise patient care?* This field is required.
Test Delayed
Test could not be completed
Test Error (or near miss)
No, it did not
Other
11
Please explain how patient care was impacted: Include as much detail as you can. No PHI.
12
Were you harmed, or was there a serious threat to your health and safety?* This field is required.
Yes
No
13
Did you fill out an iCare report?* This field is required.
Yes
No
14
Please Explain the health and safety impact on staff:* This field is required.
15
Please describe the incident and explain your concerns. Report the date, time, and duration of incident as applicable. It is helpful to include context like the number of patients waiting and special acuity. Also, how can the concerns be prevented in the future?* This field is required.
16
Date of Incident* This field is required.
Date
Month
Day
Year
17
Shift* This field is required.
Days
Evenings
Nights
18
Actions Taken:* This field is required.
I notified a supervisor
I filed an incident report (if appropriate)
A safety stop was initiated
This was resolved on my shift
No action taken
19
Your Name* This field is required.
20
Your Email* This field is required.
example@example.com
21
Job Title* This field is required.
22
Location* This field is required.
Central Lab
Emmanuel Health
EHOP
Cornell
Cedar Hills
Good Sam
GS OP
Meridian Park
MP OP
Mt. Hood
MH OP
Salmon Creek
SC OP
Camas
Silverton
23
Select OFNHP Organizer* This field is required.
David Oppenheimer
Lizard Flud
Marylou White
24
Your Classification* This field is required.
25
Supervisor/Manager's Name
26
Supervisor/Manager's Email
example@example.com
Should be Empty: