The purpose of this form is to notify hospital Supervision that you have been given an assignment which you believe is potentially unsafe for the patients and/or staff. This form will document the situation. The Union may use it to address the problem.
(Please print clearly or use the computer to fill out this form.)
One or more Registered Nurses (RN's) may complete/sign the form. Send one copy of this form to the Union via inter office mail, email it, fax it: 573-814-6606 or drop it by the office, Room 542.
One copy provide to the Supervisor or Manager on duty and keep a copy for yourself.