NHCH Safe Staffing Form

LABOR MANAGEMENT COMMITTEE
To collaborate on issues
affecting professional nursing
Safe Staffing Form
Safe staffing concerns should be communicated by thea ffected employee working in the department at the time of the safe staffing concern to the Supervisor, Nurse Manager, House Coordinator, or designee so it can be addressed in real time. If the staffing concerns cannot be reported or resolved in real time, this form will be used. Please complete and submit to the Department manager within 3 days of the concern. Changes to the form must be mutually agreed upon by the Employer and Union.
Date:

MonthDayYear
Date
Shift:
Unit
(Please complete at time of concern)
I have notified, a t 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 of the following conditions: (check all that apply)
Orientation/Experience
Check all that applies:
1. IF not trained on using equipment used to care for patient; please specify.
Patient Acuity
Check all that applies:
2. IF unplanned events; please specify (e.g., code, severe change in patient acuity)
3a. Number of patients assigned
3b. Acuity (check one)
Staffing
Lack of ancillary staff (check all that apply)
Check all that applies:
4. IF I believe the number of staff provided is/was not adequate; please specify.
5. IF poor skill mix of staff; please specify.
6a. IF missed breaks, missed meals, late meals; please specify.
6b. Time missed:

Hour Minutes

AM/PM Option
7a. # of Admits
7b. # of Discharges
7c. # of Transfers
8a. Situation:
8b. Background:
8c. Assessment:
8d. Recommendation:
Name (please print):
Signature:
Personal Email (Non-Work Email)
example@example.com
Date:

MonthDayYear
Date
Submit completed form to Unit Manager Date:

MonthDayYear
Date
Created 5/22/2025
Should be Empty:

LABOR MANAGEMENT COMMITTEE

Safe Staffing Form

Orientation/Experience

Patient Acuity

Staffing