Instructions:
- Prior to using this form, you must notify the ANC/manager in person or by phone of your need for more help. This form is to document your request. If you didn’t make the request, you can’t use it.
- Use this form only if you don’t have adequate help. If these forms are used indiscriminately and without justification, it will dilute their usefulness.
- The completed form will be submitted to your unit manager and Union.
Concern for Safe Staffing / ADO Forms serve as a means to:
- Provide your supervisor an opportunity to correct an unsafe situation
- Limit your personal and professional liability
- Document trends in staffing, patient volume and/or acuity levels for your Unit Staffing Collaborative to collect, analyze for changes in the staffing plans.
No Union member should be harassed, coerced, intimidated or discriminated against for signing a CFSS. Report any form of retaliation to your Union steward immediately.
IMPORTANT: Please do not include patient identifying information.
