Concern for Safe Staffing

As Nurses and Health Care Professionals we are obligated to speak up for our patients and our practice. The Concern for Safe Staffing form is notice to FAHC that in your assessment, based on your professional experience and knowledge, the staffing complement that you are being asked to work within is unsafe. This form is used in the systematic evaluation of staffing, it is VITAL that prior to submitting this form you communicate your concern to your management team and/or their representative AND collaborate with them to develop a plan to ensure the safety of your patients, coworkers, and yourself.

Please fill in your full name and the names of any others that share your concerns.
Please enter your Department Name or Cost Center Number. This field will autocomplete as you type. So typing in "Baird" will give you all the Baird options, "Shep" all the Shep options, etc.
How long was your shift supposed to last?

As a patient advocate, in accordance with the Nurse Practices Act, this is to confirm that I/we notified you that in my/our professional judgment, my/our assingnment is unsafe and places my/our patients at risk. I have been mandated to provide care and do not want to abandon my patient. As a result, the facility is responsible for any adverse effects on patient care.

If your issue doesn't fit well in the form details below, please use this space to describe your concerns, so we can make the workplace safer for all.
Notification You Have Given
You must notify charge nurse and manger/ANC at the time of need or concern.
Check all that apply.
Compromises in Patient Care
Comoromises in patient care necessitated by the staffing situation. Mark all that apply.
Staffing Levels

Staff Numbers
on Duty

Who Determines Staffing Levels?

Please provide your email address. We will send you a copy of this form using this address. We prefer to use your personal email address in this field.

By submitting this form you are providing notice to FAHC of your dispute for the staffing complement you are being asking to work within. When you submit this form it is submitted to the FAHC director of Nursing (or their designee) and to The Vermont Federation of Nurses and Health Professionals. Thank you for advocating for yourself, your co-workers, and the patients we care for.