Create Workload

Select Your Sector

Your Employer

Your Full Name

Your Email address

Your Telephone Number

Tags

At the time the workload issue occurred, I/we discussed the issue within unit to resolve the concern using current resources.

Name of Person Spoken to

Date of the person Spoken to:

Time of the person Spoken to:

Failing resolution at the time of occurrence, using established lines of communication, I/we sought immediate assistance from an individual(s) identified by the Employer (who could be within the bargaining unit) who has responsibility for timely resolution of workload issues.

I/We Do not agree with the resolution of my/our concern: Names

Date of Occurence

Time of Occurence

Date form submitted to employer

Enter the email address of the manager/nurse leader who should receive this workload form

Department/Unit

Workplace/Site/Location

Was there a shortage of staff at the time of the occurrence?

Select your Occupation to tell us more about vacant classifications and/or absent classifications

I/ We the undersigned Nurse(s), believe that I was/we were given an assignment that was excessive or inconsistent with quality patient care and/or created an unsafe working environment for the following reasons. (Please check factors, and provide detail below):

Staffing Shortages (see section 2)

Resident/ Work Preparation Concerns

Resident/ Work Volume

Provide written details of the occurence with specifics for Resident/ Work Volume

Details of Admissions

Details of Discharges

Number of Admissions

Number of Discharge

Number of Transfers

Number of Isolation

Lack of Resources/Supply

Interdepartmental Challenges

Exceptional Resident Factors

Other

Hospital Workload Review Form

Form Instructions

Your Information

SECTION 1: Initial Attempt

SECTION 2: Info(employer's email)

SECTION 3: Factors

SECTION 4: Solution

Section 5: Manager or Designates Response: