Staffing Request and Documentation Form

Staffing Request and Documentation Form

Formal Complaint form to SEIU Hospital Staffing Committees
Please fill out all Staffing Complaints using our new form.
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 at https://www.hhs.gov/hipaa/for-professionals/index.html.

If you have not yet completed a staffing survey please complete that form here.
Your contact information
Your name*

First NameLast Name
Your mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number
Information about your place of employment
In which state do you work?*

OregonWashington
Your job title
Please enter the full job title and avoid using acronyms or shorthand.
Shift
Length of shift
Employer name *
Please enter the name of your employer.
Facility name *
Please enter the full name of the facility and avoid using acronyms or shorthand.
Facility address, if known

Street Address

Street Address Line 2

CityState

Zip Code
Information about the violation/incident
Date of incident*

MonthDayYear
Date
Time of Incident*
Was your Unit in compliance with the staffing plan on that day?
Unit/Department or floor where the violation occurred
Please enter the full name of the unit and avoid using acronyms or short hand
What was your main concern?

Not enough staffPatient acuity too highPatient delays/wait timesOther
Concerns regarding Staff

Patient safetyUnable to take rest breakUnable to take meal breakMandatory overtimeVoluntary overtimeInjury due to work loadInjury due to patient violenceUnable to complete daily assignment, requested helpUnable to complete daily assignment, did not request helpLong patient wait times
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
Does anyone else have first-hand knowledge of the incident(s) or the problem(s)?*

YesNoI don't know
If yes, list the names, relationship/title, and if you know it, telephone contact information for any witnesses.
Have you filed a complaint with anyone at the facility/agency? If so, with whom, when, and have you received a response?*
If additional questions arise during the review process what is the best way to contact you?*
Is short staffing chronic?
Have shift vacancies been a long standing issue?

YesNo
Is there a longstanding vacancy in the department that has been unfilled within 60 days?

YesNo
Are you understaffed? ("understaffed" meaning there is more work than there are employees to complete tasks during shift)

YesNo
Are their frequent holes in the schedule?

YesNo
Are vacations and leaves of absences being backfilled? (meaning, another employee covers those duties, NOT duties divided by remaining staff)

YesNo
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

Your contact information

Information about your place of employment

Information about the violation/incident

Is short staffing chronic?