Documentation of Assignment Dispute - Hahnemann Nurses United
NOTE: Supervisor must be informed as soon as inadequate staffing situation is known. By filling out and signing this form, you understand that the information it contains is shared with PASNAP and with management in order to address the situation.
Date *
MM
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DD
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YYYY
Unit
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Name of Supervisor Notified
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Reason for Assignment Dispute
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List of Auxiliary Help (please specify, e.g. AA, ICUA, Tech, Other)
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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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Staffing Count on Shift Objection - RNs
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Number of Staff Requested to Provide Coverage
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Signatures
We, the undersigned nurses, support the above documentation. As a result of the above inadequate staffing, our patients 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 6 - Email Address
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Signatory 7
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Signatory 7 - Email Address
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Signatory 8
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Signatory 8 - Email Address
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