NYS Staffing Form
Date
*
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Month
-
Day
Year
Date
Name(s) of Individual(s) Reporting
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Shift
Please Select
Days
Evenings
Nights
Date of Staffing Violation
*
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Month
-
Day
Year
Hour Minutes
AM
PM
AM/PM Option
Facility
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Department/Unit
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Submitted by
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RN's
LPN's
Other (ex. 1:1; supervisor)
Orientees
Students
Bed Capacity
Census
# of 1:1's
For what reason(s) are you reporting this violation?
*
Please Select
Patient acuity is higher than planned
Volume of admissions and discharges
Not adequately trained for this situation
Case load is too high and impedes safe care
Inadequate number of qualified staff
Do not have resources needed (supplies, equip, meds)
Inadequate time for documentation
Mandatory Overtime
Other
If other, what?
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Scenario of Staffing Issue
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By checking this box, it serves as protest of assignment
Name of manager/supervisor notified
*
Please Select
Shannon Ostrowski - Emergency Department
Tim Curry - Hall 4
Tim Curry - Endoscopy
Tim Curry - ASU
Rebecca Lawrence - Operating Room
Jennifer Mueller - Clearview
Rebecca Lawrence - PACU
Provide more information
*
Submit
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