Staffing Concern Documentation Form
Document staffing concerns, actions taken, and manager responses. Please complete after your shift if you experience an unsafe assignment.
Instructions and Ethical Considerations
If you believe your assignment is unsafe, verbally notify your supervisor immediately and attempt to resolve the situation. After your shift, complete this form to document your concern. Refer to your contract for submission timelines. This form does not replace other incident or grievance forms and must be used in conjunction with other reporting as needed.
Staff Member's Full Name
*
First Name
Last Name
Title/Role
*
Please Select
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Charge RN
Float Nurse
Agency Nurse
CNA/Aide
Other
Facility/Clinic Name
*
Please Select
Care Center of Honolulu
CareResource Hawaii
Hale Makua
Hale Nani
Hawaii Care Choices
Kahi Mohala
Kahuku Medical
Kaiser Foundation
Kauai Medical Clinic
Kuakini Geriatric Care
Kuakini Medical Center
Kulana Malama
Liberty Dialysis Hawaii (Fresenius)
Oahu Care Facility -CNA
Oahu Care Facility - RN/LPN
Pohai Nani
Rehab - RN/LPN
St. Francis Community
US Renal Care
Wahiawa General
Wilcox Memorial
Unit/Department
*
Date of Assignment
*
-
Month
-
Day
Year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Scheduled Shift Length (hours)
Overtime Hours Worked (if any)
Unit Capacity and Patient Census
Provide details about the assignment and patient load.
Patient Census During Shift
*
Maximum Ratio of RN to Patients (if applicable)
Acuity System Used (if known)
Number of High Acuity Patients
Number of Average Acuity Patients
Number of Low Acuity Patients
Admissions During Shift (#)
Discharges During Shift (#)
Transfers During Shift (#)
Triage Scheduled Appointments (#)
Walk-Ins (#)
Objection to Assignment Details
Describe the factors impacting your ability to provide safe care. Check all that apply.
Factors Impacting Safe Care (select all that apply)
*
Staffing inadequate for acuity level of patients
Staffing inadequate for number of patients
Staffing inadequate for number of triage/scheduled appointments
Staffing inadequate due to high patient census
Insufficient ancillary staff
Missing or broken equipment not replaced or repaired
Unit geography/layout not conducive to safe care
Skill mix of staff inadequate (e.g., new grads, RN/LPN mix, floats)
Staff not adequately oriented to unit
Insufficient or no training on patient care procedure/equipment
Other factors (please describe below)
If Other factors or insufficient training/equipment, please specify:
Unit Composition at Time of Objection (check all that apply)
Charge/Team Leader assigned
Charge/Team Leader unassigned
Ward Clerk/Unit Secretary present
Regular RN
Float Nurse
LPN
MA/Tech
CNA/Aide
Agency Nurse
Other
Please list the number of staff present for each type selected above (if known):
Working Conditions (select all that apply)
Worked mandatory/involuntary overtime
Worked voluntary overtime
Missed a meal
Missed a break
Late meal
Worked longer than felt was safe
Description of Objection (please describe the incident in detail)
*
Did the outcome of this assignment also require an occurrence or incident form?
*
Yes
No
N/A
Was additional staff requested from another staffing department?
*
Yes
No
N/A
If yes, what type of staff was requested?
Result of staff request
Staff provided
Staff not provided
Supervisor/Charge Nurse notified (name)
Date/Time of Notification
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Actions Taken (select all that apply)
*
Carried out assignment under protest to the best of my ability
Reported the incident that I witnessed
Additional Comments or Follow-Up
Staff Nurse Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
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