Observe HIPAA patient privacy when completing this form.

If your work area is in violation of the law or if you personally are unable to provide safe, quality patient care, complete this form. By doing so, you are creating a record of this violation and advocating for your patients!

Question Title

* 1. Name

Question Title

* 2. Hospital

Question Title

* 3. Unit

Question Title

* 4. Date

Question Title

* 5. Shift

Question Title

* 6. Mobile Number*
*By providing my mobile phone number, I understand that SEIU and its locals and affiliates may use automated calling technologies and/or text message me on my mobile phone on a periodic basis. SEIU will never charge for text message alerts. Carrier message and data rates may apply to such alerts. Text STOP to 787753 to stop receiving messages. Text HELP to 787753 for more information.

Question Title

* 7. Name of your SEIU Local 121RN Union Rep/Organizer

Question Title

* 8. Unit Census at the time:

Question Title

* 9. Patient Acuity (overall) at the time:

Question Title

* 10. Staff on duty during shift in question:

Question Title

* 11. Concern/Violation (please check all that apply)

Question Title

* 12. If you checked off that you were assigned more patients than the Title 22 regulation, please indicate the number of patients over ratio:

Question Title

* 13. If you checked off that there was a reduction in support staff, please indicate numbers reduced for this shift:

Question Title

* 14. Please provide more details if you indicated that you missed breaks and/or worked overtime

Question Title

* 15. What actions did you take to object to the concerns/violations?

Question Title

* 16. Describe, in detail, the impact on patient(s) and staff. Include any other event(s) that adversely affected patients and/or staff. Was there potential or actual negative patient outcome?

Question Title

* 17. Additional steps I've taken:
(Please check all that apply)

Question Title

* 18. Health & Safety Concerns/Violations:
Detailed description of the hazard and its location. For example: full sharp containers, failure to provide safe patient handling equipment, patient handling injuries, failure to provide PPE, etc.

Question Title

* 19. Health & Safety Concerns/Violations:
Have any employees been injured as a result of the conditions?

Question Title

* 20. Health & Safety Concerns/Violations:
Nature of the work performed in the area of the workplace which is the subject of concern:

Question Title

* 21. Health & Safety Concerns/Violations:
Type and condition of any equipment or machinery in use in the subject workplace and any materials, chemicals, processes or operations involved:

Question Title

* 22. Health & Safety Concerns/Violations:
How long the hazardous conditions have existed, have the conditions been brought to the employer's attention and, if so, has the employer made any attempt to correct the condition?

T