ADO / Staffing Concern Form

Use this form to submit a complaint to the Nurse Staffing Committee and WSNA Nurse Representative.

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My concern

In my professional opinion, the situation described here is not adequate to meet the needs of the patients assigned to me at this time. Please be aware that while I will do all that I can to ensure safe and proper care for my patients, I fear that my efforts and those of the staff may not be sufficient. Therefore, I am informing you that I am concerned about the possibility of any errors or incidents that may take place as a result of this unsafe condition created by inadequate staffing, systems / equipment failures.

Staffing: Our unit is not staffed according to its staffing plan

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Staffing: Shift adjustments are inadequate

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Equipment

Check all that apply.

System failure

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Missed breaks

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Earned time denied

Check all that apply.

Please describe.

Please provide details about the incident you are reporting

Actions taken

After you submit this form...

A copy will be sent to your Local Unit Chair and Vice/Co-Chair, Staffing Committee co-chairs and WSNA Nurse Representative. You will receive a copy of this completed form. To send a copy to your manager, please enter their e-mail address below.

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