NYPNU Contract Violation Reporter
Please use this form to report any contractual violations including: mandatory overtime, missed breaks, charge RN violations, and ratio violations.
Name *
Your name will allow us to follow up with you regarding answers you've provided and file a grievance on your behalf, as necessary.
Your answer
Best phone number to reach you at: *
Your answer
Which shift do you work? *
(assigned shift)
Are you full-time, part-time, or per-diem? *
Choose one (1)
Were there any other staff members affected by or witness to the incident?
Please include full names and title (RN, NA, Manager, security, etc)
Your answer
What is your assigned unit? *
(If you're a Case Manager, choose CM option, not the unit which you are assigned to work)
Date of Incident *
MM
/
DD
/
YYYY
Were there any sick calls on date of incident? *
What violation would you like to report? *
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