HPH General Safe Staffing

  • SAFE STAFFING FORM

  • IMPORTANT: You are encouraged to complete this form prior to clocking out and leaving the facility (you will be paid for your time). Complete and submit within 7 days of incident:
    1) Keep a copy for yourself
    2) Email a copy of the completed form to your manager/supervisor.

     

    DO NOT ADD PATIENT INFORMATION

     

  • Prior to filling out a Safety Concern Form, follow the chain of command (as applicable): Charge Nurse, House Supervisor, Supervisor, Manager

  • As a patient advocate, this form confirms my notification to you that, in my professional judgment, today's assignment is unsafe and places my patients at risk. As a result, I will under protest carry out the assignment to the best of my ability.
  • RN, protest my assignment on
     - -
  • Check all that apply:
  • 2. If I was not given the number of staff provided acuity:
  • Lack of staff on shift of objection:
  • Date
     - -

  • The safe staffing form is (to be filled out by Nurse):

    • Resolved and this form will serve as a written response. Action Taken:
    • Unresolved. HNA will receive an additional follow up in writing from the appropriate unit manager within seven (7) working days.
  • Employees who raise staffing issues and/or initiate a staffing concern shall be free from any reprisal or retaliation. If there is more than one person filling out form for the same situation and not resolved, please provide a contact person to assist with answering questions if needed from both the Union and Management.
  • Format: (000) 000-0000.
  •  
  • Should be Empty: