FEDERATION OF NURSES/UFT
FNHP/AFT – AFL-CIO
52 Broadway
New York, NY 10004
(212) 420-7981

STAFFING INCIDENT REPORT

TO: ________________________________________, Supervisor 

FROM: ________________________________________, RN                  

UNIT                CENSUS               SHIFT                DATE

_________        ________              ________            _______

I have notified you at the start of this shift that the staffing provided is not adequate to meet the nursing care needs of the patients on this unit at this time. You have failed to provide proper staffing.

Please be aware that while I do all that I can to ensure safe and proper nursing care for my patients, I fear that my efforts and those of the staff will not be sufficient.

Therefore, I am informing you that I cannot take responsibility for any error or incidents that take place as a result of the unsafe conditions the Hospital has created.

PRINT NAME CLEARLY                         SIGNATURE

_________________________            ________________________

_________________________            ________________________

_________________________            ________________________

_________________________            ________________________

Please submit the original to your supervisor. Make at least one copy for yourself and send a copy to: 

Anne Goldman, Federation of Nurses/UFT, 52 Broadway, New York, NY 10004.

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        One Copy - For Yourself                                     One Copy - FN/UFT

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