Concern For Assignment Form - Oklahoma Nurses Association
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2O
N
A
KLAHOMA
URSES
SSOCIATION
D
C
A
OCUMENTATION OF
ONCERN FOR
SSIGNMENT
Purpose:
The purpose of this form is to notify your supervisor and document your concerns regarding a potentially unsafe patient
care assignment.
Instructions:
Discuss the situation with your charge nurse and notify your supervisor of your concern about the assignment. Initiate
this form, to document your concerns and the details of the situation. Complete the response section with the supervisor’s
response, as well as the date and time of the response. If you do not receive a response from your supervisor, submit a
copy of the completed form to the next level of administration.
Section 1:
I _____________________________________________, Registered Nurse employed at ________________________
on
Facility
Unit/shift
Hereby document my concern regarding this assignment as:
__Staff Nurse __ Nurse in Charge __RN pulled to unit
other _________
made to me by _____________________________ at ________________
Supervisor’s Name/Title
Date/Time
Response:_________________________________________________________________________
Other persons notified:
_____________________________________ ____________________ ______________________
Name
Date/Time
Response
____________________ ____________________ ______________________
Name
Date/Time
Response
Section 2: I am stating my concerns about this assignment, because, I believe the following conditions exist: (check all
appropriate statements)
Staff not trained or experienced in area assigned
Inadequate staff for acuity
Assignment posed serious threat to health/safety of
Unit staffed excessively by agency
staff
Staff pressured to work beyond scheduled hours
Staff not given adequate orientation in area assigned
Unit staffed with unqualified personnel
Assignment posed potential threat to health/safety of
Unit staffed with inappropriate personnel
patient
New patients were transferred or admitted without
adequate staff
Other (explain)____________________________________________________________________________________
_________________________________________________________________________________________________
Section 3: Patient census at the time of your objection: (Indicate the number of patients for each acuity level). If
there are acuity factors not identified, please specify:
Patient Census ___ Unit Capacity ___ Admissions ___ Discharges ___
Acuity Levels: High ___ Average ___ Low ___
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