Skip to content
Staffing Report Form
Tracking data is the first step to understanding and advocating for improved staffing.
By completing this survey, you are standing in solidarity to improve staffing at your facility. Thank you for taking the time to make a difference.
*
Member Name:
(Required.)
*
Personal Email:
(Required.)
*
I work at:
(Required.)
Alaska Regional Hospital
Prestige Long-term Care
Baxter Senior Living
*
Location of staffing concern (Dept, Unit, Court, other):
(Required.)
*
Date of staffing concern:
(Required.)
*
Time of staffing concern:
(Required.)
*
Did this concern cause patient or staff harm?
(Required.)
Yes
No
If this concern is related to Workplace Violence, please select from the following:
Patient toward staff
Staff toward staff
Visitor toward staff
Visitor toward patient
Other (please specify)
If this concern is related to a system failure, please select from the following:
Computers/computer program
Medication dispenser (Pyxis, other)
Medication bar code scanner
Telephone or Call system
Other (please specify)
If this concern is related to missed breaks or lunch, please select from the following:
Missed one break
Missed two breaks
missed three breaks (12 hour shift)
missed lunch/dinner
Other (please specify)
If this concern is related to assignment concerns, please select from the following:
Overstaffing - I was sent home
Patient acuity is too high for existing staff
Patient to staff ratio is too high
Inappropriate assignment for skill level of nurse
Inappropriate assignment for skill level of support staff
Charge nurse taking patient assignments and/or unable to perform charge nurse duties
Forced/Mandatory OT/Misuse of prescheduled call
Other (please specify)
If this concern is related to equipment and supplies, please select from the following:
Unavailable
Substandard/broken
Not trained to use equipment/supplies
Other (please specify)
If this concern is related to earned time being denied, please select from the following:
Denied PTO
Denied Extended Illness
Denied Education Leave
Other (please specify)
Brief Description
Please provide a brief description of your concern/incident:
Actions Taken in addition to completing this Staff Report Form:
I filed an incident report
This was resolved on my shift
I notified my supervisor
Other
Other (please specify)
