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Unsafe Staffing

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Name

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Objection and Documentation of Unsatisfactory Staffing

This form is being used by the MNA to report any instances of unsatisfactory and unsafe nurse staffing in a Hospital Setting. If you work in a Community setting please use the Community Setting Form.

Download reporting form as a PDF, or use the interactive form below:

Name

Title

Facility

Shift

Unit

Section I – Unsafe Staffing

I hereby object to the assignment as:

Check all that apply

Given an assignment which poses a serious threat to patient’s health and safety

Not oriented to unit

Case load assignment is excessive and interferes with delivery of safe and adequate care

Transferred, discharges, or admitted new patients to unit without adequate staff

Not given appropriate staff for census:

inappropriate number of temp. professional personnel

inappropriate number of unlicensed personnel

inappropriate number of professional staff

not provided with unit clerk

other

Staffing count at time of objection

Regular

Float/Casual

Agency

Ancillary

Regular

Float/Casual

Agency

Secretary

Regular

Float/Casual

Agency

Patient census at time of objection:

Unit capacity:

Acuity

amt. of nursing care required

Acute

High

Average

Staff needed to provide safe patient care:

Brief statement of problem and effect on patient care:

Nurse Manager/Supervisor Notified

Name of Supervisor/Manager

Date

MM slash DD slash YYYY

Time

Hours

Minutes

AM/PM

Response

Email*

This email will be used to send a copy of this form for your records.

Phone

Optional

Signature*

Initials, please

Today's Date

MM slash DD slash YYYY