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Local 3295 Oregon State Hospital Registered Nurses

Fax 503-370-7725


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.