PURPOSE:
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.
INSTRUCTIONS:
(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.