Staffing Request and Documentation Form

Staffing Request and Documentation Form

Formal Complaint form to SEIU Hospital Staffing Committees
This is a form is to formally request additional staffing and report shortages in staffing. This short form will be submitted to your union, SEIU 49, to help us track incidents.

Upon submitting this form, you will be redirected to the new, official form for Oregon or Washington depending on which state you work in.

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.
Your contact information
Your name*

First NameLast Name
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.
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.
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
Why are you filing this complaint?*

Employer not following staffing ratiosMissed or late lunchMissed or late breakAssigned tasks instead of patientsAssigned tasks and patients (provided care for more then the ratios)Other
Should be Empty:

Staffing Request and Documentation Form

Your contact information

Information about your place of employment

Information about the violation/incident