Staffing Request and Documentation Form

Staffing Request and Documentation Form

Formal Complaint form to Hospital Staffing Committees, OHA and SEIU
This is a form is to formally request additional staffing and report shortages in staffing. The form will be submitted to your local hospital staffing committee, your union, and the Oregon Health Authority.

After the form is completed, please submit the form to your manager, your facility wide staffing committee, and any other relevant commmittee including the safety committee of your facility.

Be sure to observe HIPAA compliance requirements when submitting this form and remove any patient identifying information. You can find out more about HIPAA compliance here:

https://www.hhs.gov/hipaa/for-professionals/index.html

If you have not yet completed a staffing survey please complete that form here:
In what state do you work? *

Oregon Washington
Facility Name *
Please enter the full name of the facility and avoid using acronyms or short hand.
Name *

First Name Last Name
Email *
example@example.com
Phone Number

Area Code Phone Number
Job Title
Please enter the full job title and avoid using acronyms or short hand.
Unit/Department or Floor where the violation occurred
Please enter the full name of the unit and avoid using acronyms or short hand
Shift
Length of Shift
Date of Incident

Month Day Year
Date
Time of Incident
Was your Unit in compliance with the staffing plan on that day?
What was your main concern?

Not enough staff Patient acuity too high Patient delays/wait times
Concerns regarding Staff

Patient safety Unable to take rest break Unable to take meal break Mandatory overtime Voluntary overtime Injury due to work load Injury due to patient violence Unable to complete daily assignment, requested help Unable to complete daily assignment, did not request help Long patient wait times
Is short staffing chronic?
Have shift vacancies been a long standing issue?

Yes No
Is there a longstanding vacancy in the department that has been unfilled within 60 days?

Yes No
Are you understaffed? ("understaffed" meaning there is more work than there are employees to complete tasks during shift)

Yes No
Are their frequent holes in the schedule?

Yes No
Are vacations and leaves of absences being backfilled? (meaning, another employee covers those duties, NOT duties divided by remaining staff)

Yes No
Description of your concerns regarding the staffing incident or day.
Examples: Delay in patient care, concerns regarding cleanliness, concerns regarding patients mental health or family support
I am informing you that I believe our unit is currently understaffed and that the number of staff assigned to the unit is inadequate to meet patient care needs. I am requesting that a formal assessment is done to increase the number of staff in our unit and or department.
Signature

Clear
Should be Empty:

Staffing Request and Documentation Form

Is short staffing chronic?