• STRAUB - HNA Staffing Concern Form

    For Registered Nurses to document unresolved safe staffing concerns at Straub Medical Center. Do not include any patient identifying information.
  • Instructions

  • The purpose of this form is for Registered Nurses to document unresolved safe staffing concerns with their Manager, who shall review, address and take action as appropriate. Please complete this form at the end of your shift if the staffing concern remains unresolved. Do NOT include any patient identifying information. For further details, refer to Section 32.6 of the CBA. Employees who raise staffing issues and/or initiate a staffing concern shall be free from any reprisal or retaliation. If you have questions or feel your rights have been violated, contact HNA or your steward. Phone: (808) 531-1628. May 2023.

  • Date of Assignment*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Start Time of Assignment*
  • End Time of Assignment*
  • Your Role During Assignment*
  • I/we under protest carried out the assignment to the best of my/our ability and believe this situation carries a potential safety issue. I/we have given the appropriate notification to management.

  • Unit Composition at Time of Objection

    Please provide the following details about unit staffing and capacity during the shift.

  • Notification Details
    You must notify the supervisor or manager at the time of concern.

  • Date & Time Notified*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Factors Impacting Ability to Provide Safe Nursing Care (Check all that apply)*
  • Did the outcome of this assignment also require an incident form?*
  • As a result of this incident, I/we (check all that apply)

  • By Signing, I attest that the stated RNs do agree to this submission and designate me as point person for written follow up with manager.

  • After this form is submitted, a copy will be sent to HNA, your LRS, and to the email you entered above. You must forward that email to your manager.

  • Should be Empty: