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:
-
Month
-
Day
Year
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
Not trained on using equipment used to care for patient: (specify)
Other
Not oriented to the unit
Not experienced in providing care for the type of patients on unit
Patient Acuity
Unplanned events (specify) (e.g., code, severe change in patient acuity)
Other
Case load assignment is excessive/acuity and interferences with delivery of adequate patient care
Number of patients assigned Acuity (check one)
Number of patients assigned
high
medium
low
Staffing
I believe the number of staff provided is/was not adequate. Reason:
Other
Lack of ancillary staff (check all that apply)
Lack of ancillary staff (check all that apply)
housekeeping
pharmacy
clerical
nurse aide
maintenance
Poor skill mix of staff (specify) (e.g., large proportion of less experienced or float staff)
Other
Transferred, discharged, admitted new patient(s) to unit without adequate staff
# of Admits
# of Discharges
# of Transfers
Missed breaks
Missed meal
Late meal
Time:
Hour Minutes
AM
PM
AM/PM Option
Other: (Situation, Background, Assessment, Recommendation)
Other
Situation:
Background:
Assessment:
Recommendation:
Name (pleaseprint):
Signature:
Date:
-
Month
-
Day
Year
Date
Submit completed form to Unit Manager Date:
-
Month
-
Day
Year
Date
Created 5/22/2025
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