Local 3295 Oregon State Hospital Registered Nurses
Fax 503-370-7725
(SEE ATTACHMENT BELOW FOR DOWNLOADABLE DOCUMENT)
Staffing Request and Disclaimer of Liability
Date_________ Time_________ Shift_________ Unit__________ Time Emailed___________
Report and request: I am hereby reporting that in my professional judgment as Registered Nurse, I am unable to assure safe and adequate care of the patients in my assigned unit. The reasons for my decision and requested remedies are as follow.
(Check all that apply)
___I am physically or mentally unable to work a mandated shift starting at _________(time).
___Acuity of patients is too high for assigned staffing.
___Insufficient staff have been assigned for 1:1’s and other duties.
___Assigned staff are untrained or not oriented.
___I have been assigned additional duties that conflict with my ability to complete my regular duties.
___Other (explain circumstances) _________________________________________________________________________________
__________________________________________________________________________________
I request the following remedies be provided:
(Check all that apply)
___I should be replaced for the shift
___Additional staff should be assigned
___Number of additional staff
___Number of additional RNs
___Other (explain) _______________________________________________________________________________
________________________________________________________________________________
I am accepting the assignment under protest, I will not refuse the assignment or refuse to obey direct orders, if any are given. I am doing so to avoid any appearance of not meeting my obligations to my patients. However, I am giving my employer notice of my concerns. Full responsibility for the consequences of this assignment must rest with the employer. Copies of this form may be provided to all appropriate state and federal agencies and my union.
Nurse’s name: ______________________________ Signature: __________________________________
Send the completed form by email to your supervisor, the nurse staffing committee co-chairs and the AFSCME Local 3295 union president.
local_3295_staffing_request_and_disclaimer_of_liability.pdf