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. Question Title * 1. Member Name: Question Title * 2. Personal Email: Question Title * 3. I work at: Alaska Regional Hospital Baxter Senior Living PACS Long-Term Care Center Providence Hospital Question Title * 4. Location of staffing concern (dept. unit, court, etc.) Question Title * 5. Date and time of incident/concern: Date / Time Date Time AM/PM - AM PM Question Title * 6. Did this concern cause patient or staff harm? (Required.) Yes No Question Title * 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) Question Title * 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) Question Title * 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) Question Title * 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) Question Title * 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) Question Title * 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) Question Title * 13. Brief description of the incident/concern: Question Title * 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) Done
