Use this form to submit a complaint to the Nurse Staffing Committee and WSNA Nurse Representative.
(Required)
(Not required but helpful)
(Required) Please provide a personal (i.e. non-work) email address where we can reach you.
In my professional opinion, the situation described here is not adequate to meet the needs of the patients assigned to me at this time. Please be aware that while I will do all that I can to ensure safe and proper care for my patients, I fear that my efforts and those of the staff may not be sufficient. Therefore, I am informing you that I am concerned about the possibility of any errors or incidents that may take place as a result of this unsafe condition created by inadequate staffing, systems / equipment failures.
Select one.
Check all that apply.
Check all that apply
Please describe briefly (maximum 300 characters)
A copy will be sent to your Local Unit Chair and Vice/Co-Chair, Staffing Committee co-chairs and WSNA Nurse Representative. You will receive a copy of this completed form. To send a copy to your manager, please enter their e-mail address below.
(Required) So that a copy of this form can be sent to your manager, enter their email address here.
