UWMC-Northwest CNA Short Staffing Form

Upon submitting this form, you will receive a copy of your answers in your email. 
1. Forward a copy to your manager
2. Forward one copy to your unit’s delegate and/or union organizer.

Reporting CNA Name(s) *

First

Last

Additional Names (optional)

Date/time *

Unit *

Shift *

I have made my objection known to my supervisor/manager/charge nurse: *

• Yes
• No

My ability to provide quality patient care has been compromised because of the following (check or explain as needed):

# of RNs *

# of CNAs on the Floor *

# of CNAs Needed *

Current Census *

Please explain as needed:

2. Not trained/experienced in assigned area:

• Yes
• No

Please explain:

3. Other, please explain:

What factors contributed to staffing concerns? (check or explain as needed)

• Overtime not approved
• No staff available to come in
• No float staff available to fill holes
• Staff pulled to other unit(s)
• New patient admits/transfers/discharges

Other, please explain:

As a result of short staffing, patient care has been compromised (check all that apply):

• Charge nurse notified of the unsafe staffing
• Patient/family dissatisfied with care
• Missed/delayed turn
• Patient transferred to other units
• Missed/delayed meal
• Post Op VS delayed
• Patient fall

Other, please explain:

As a result of short staff, job satisfaction has been compromised (check all that apply):

• Missed/delayed meal
• Missed/delayed break
• Delayed charting
• Delayed bathroom break

Other, please explain:

In my professional judgment, today’s staffing assignment is unsafe and places our patients at risk. I will, under protest, attempt to carry out the assignment to the best of my ability.

Signature *

Clear Signature

Today's date *

Email (for a copy of your responses) *

Submit