Short Staffing Form (CNA, Tech, Service) – Forms

Short Staffing Form (CNA, Tech, Service)

Name *

First

Last

Date / Time *

Date

Time

Double click on a single date to select it.

Unit *

Shift *

Employer *

* If you are a member of another union, go to wsna.org for WSNA, or ufcw3000.org for UFCW3000

I have made my objections known to

(supervisor)

(title)

That this assignment has compromised my ability to provide quality patient care because of the following:

Inadequate staff for acuity
Insufficient number of RNs
No HUC
Insufficient ancillary staff (explain below)
I was not oriented to the unit
Inappropriate assignment for skill level of RN or coworkers
Other:

Explain

Staffing Pattern

Census

Bed capacity

Acuity

High
Average
Low

Admits

Transfers

Discharges

RNs

Float RNs

LPNs

Nursing Assistants

Unit Secretaries

Other

Was the staffing matrix or plan for the unit followed?

Briefly describe the problem:

Action taken:

Outcome:

Signature of staff issuing unsafe/inadequate staffing objection: *

Clear Signature

Submission instructions

A copy of this submission will be emailed to the email you provide below. Under the additional emails field, add:

Email for charge nurse and unit supervisor or nurse manager.
Email for your union delegate, Executive Board member and/or union organizer.

Write and attach a more thorough written documentation when you are off duty, if necessary. Also complete an Incident Report in case of any harm or potential harm to a patient.

Your Email *

Additional Emails

Recommended:
Copy to charge nurse and unit supervisor
Copy to union delegate/Executive Board member
Copy to union organizer

SEIU Healthcare 1199NW