Did the supervisor attempt to call in additional staff? *
Did the supervisor offer OT? *
Did the supervisor utilize agency staff? *
RL Number, If Filed:
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Reason for Short Staffing:
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Unit Specialty:
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Unit Capacity:
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Patient Census on Shift Start:
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Patient Census At Time of Dispute:
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Describe Assignment and Acuity:
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Outcomes of Inadequate Staffing
Number of Staff at Time of Objection (RNs)
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Number of Staff at Time of Objection (LPNs)
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Number of Staff at Time of Objection (Ancillary)
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Number of Staff at Time of Objection (Techs/Professionals)
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Number of Staff Requested to Provide Proper Coverage
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Signatures
We, the undersigned nurses and/or professionals, support the above documentation. As a result of this inadequate staffing, our patient(s) did not get the best care possible.
Signatory 1
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Signatory 1 - Email Address
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Signatory 2
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Signatory 2 - Email Address
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Signatory 3
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Signatory 3 - Email Address
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Signatory 4
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Signatory 4 - Email Address
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Signatory 5
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Signatory 5 - Email Address
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Signatory 6
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Signatory 7
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Signatory 8
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Signatory 8 - Email Address
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