Concern For Safe Staffing Form

One of the primary obligations I have as a nurse is to keep patients safe. I am advocating for my patients when I notify someone in management, that, in my professional judgment, the staffing is unsafe and help is needed. This form is to document my efforts to advocate and protect patients from harm. While I can choose to give this completed form to my manager, the reality is my communication at the time the issue is occurring is the crucial conversation that needs to happen.




(A copy of the completed form will automatically be sent to the e-mail address you enter)





















(NOTE: The detailed explanation/narrative you write in this box will NOT be included on the hard copy of the form that you can print off and share with your supervisor after you hit "Submit." However, the detailed explanation/narrative you write in this box WILL be included in the electronic copy of this submission that is e-mailed to MNA and to yourself if you included your e-mail address on the form.)


(NOTE: This information regarding PR usage will NOT show up on the printed version of the form that you turn in to your supervisor.)