Queens Safe Staffing Form

LABOR MANAGEMENT COMMITTEE
To collaborate on issues affecting professional nurses
Documentation of Concern for Safe Staffing for Patient Care
The purpose of this form is to document a staffing concern, the action taken by each nurse to remedy the staffing problem, and the response of the supervisor. It is a tool to communicate, and to avoid similar situations in the future.
Bargaining Unit
Department (QMC RN)
Date of Incident

MonthDayYear
Date
Shift
(Please complete at time of concern)
I have notified, at the time of the incident (name)
(management position)
that in my professional opinion, I am unable to assure the delivery of safe or adequate nursing care because following conditions. (check all that apply)
Orientation/Experience
1. IF not trained on using equipment used to care for patient; please specify
2. IF not oriented to the unit; please specify
Patient Acuity
Check all that applies:
3. IF unplanned events; please specify
4a. IF number of patients assigned; please specify (# of patient)
4b. Acuity (check one)
Staffing
Lack of ancillary staff (check all that apply)
Check all that applies:
5. IF I believe the number of staff provided is/was not adequate; please specify.
6. IF Acuity system does not reflect patient need/acuity accurately; please specify.
7. IF Poor skill mix of staff; please specify.
8a. IF missed breaks, missed meals, late meals; please specify.
8b. Time missed:

Hour Minutes

AM/PM Option
9a. # of Admits
9b. # of Discharges
9c. # of Transfers
10a. Situation:
10b. Background
10c. Assessment:
10d. Recommendation:
I indicate my acceptance of the assignment despite objection. I will, despite objection attempt out to carry out the assignment to the best of my professional ability. However, I hereby give notice to my employer to the above facts.
Name (please print):
Personal Email (Non-Work Email)
example@example.com
Signature Field
Date & Time:

MonthDayYear
Date
Submit completed form to Unit Manager
Send a COPY to HNA or Unit Chairperson and keep a copy for your files.
Approved: LMC 10/17/06
Should be Empty:

LABOR MANAGEMENT COMMITTEE

Documentation of Concern for Safe Staffing for Patient Care

Patient Acuity

Staffing