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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.
*
1.
Member Name:
(Required.)
*
2.
Personal Email:
(Required.)
*
3.
I work at:
(Required.)
Alaska Regional Hospital
Baxter Senior Living
PACS Long-Term Care Center
Providence Hospital
4.
Location of staffing concern (dept. unit, court, etc.)
5.
Date and time of incident/concern:
Date / Time
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Hour
Time
:
Minutes
AM/PM
-
AM
PM
6.
Did this concern cause patient or staff harm? (Required.)
Yes
No
7.
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)
8.
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)
9.
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)
10.
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)
11.
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)
12.
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)
13.
Brief description of the incident/concern:
14.
Actions taken in addition to completing this Staffing Report Form:
I filed an incident report
This was resolved on my shift
I notified my supervisor
Other (please specify)
