Fill Out The Staff Discrepancy Form For Your Unit

Posted by daniellaaird on December 1, 2011

Please use the forms below to report staffing discrepancies. It is very important that we document this information, in light of the recent furloughs at Jackson Health System

You can report staffing discrepancies two ways:

  • Print out a hard copy of the staffing discrepancy report and fax it to our union office. Click on the links below to obtain the form:

Staff Discrepancy Form

Staffing Ratio Form

  • Enter your information in the online form below:
Staffing Discrepancy Report
Date

MM

 /

DD

 /

YYYY
Unit
Shift
What is the issue?

What is the current staffing mix? Enter the number in the boxes below:
RN:
LPN:
Ancillary Staffing:
Nursing Assistant:
Secretary:
What is the current nursing staffing now?
What is the normal staffing ratio in your unit?
Were you floated to this unit?
What is the census?
How many agency nurses used?
How many overtime nurses used?
How many pool nurses used?
How many furloughs taken?
Other Unit Conditions:
Comments/Recommended Solutions:
Did you notify your charge nurse? If so, provide name:
Date/Time Notified:

MM

 /

DD

 /

YYYY

HH

 :

MM

AM/PM
Check One:
I have not been adequately trained or oriented to this area (or procedure) and/ or have not been given the appropriate
cross-training checklist.
This assignment is not consistent with staffing guidelines according to policy and protocol of JMH and/or does not permit me to execute my care according to the standard of excellence promoted by Jackson Memorial Hospital.
In my professional opinion, there are not enough nurses for safe patient care.
In my professional opinion and experience, the patient assigned to me should be in critical care area and with appropriate
critical care staffing.
Because I could be disciplined for refusal, and in adherence to the Nurse Practice Act, I do not wish to abandon the patient and, therefore, I accept this assignment. I request immediate remedial action by management; I disclaim liability for any acts or omissions that may result from my acceptance of this assignment; and, I hereby notify management that I am accepting under protest.

Because this assignment is unsafe, and inconsistent with quality patient care, I am additionally filing an incident report.
Please include incident report number:
Person Initiating Report:
Work Phone
### - ### - ####
Home Phone
### - ### - ####
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