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:
If you have not yet completed a staffing survey please complete that form here: