SEIU Member Documentation Form

The purpose of this form is for SEIU members at Allina Hospitals to document concerns arising due to short staffing and changes to staffing grids. Union leaders and stewards will use the information documented here to advocate for improved staffing levels at the hospitals. Please reach out to your union leaders directly if you want a response: click here to find their contact information.

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Contact Information

First Name Last Name

Email

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(Optional)

Additional Information

Hospital

Job Title: (Optional)

Unit/Department: (Optional)

Shift: (Optional)

Date of Concern: (Optional)

Concern (Check all that apply) (Optional)
Concern (Check all that apply) is required.

I missed my break(s)

I was overwhelmed with work, could not work at a reasonable pace

I had to ask my manager how to prioritize my work, did not finish all tasks

I felt forced to rushed, putting myself and patients at risk

I had to continue working past the end of my shift (incidental overtime)

A call light was on for over a half hour before we could respond

I was responsible for patients in two circles/areas

I was responsible for 15 or more patients by myself

I got injured

There was a patient safety event (fall, bedsore, infection due to inadequate care)

There was a patient care concern (patient on video monitor who needed 1-1, etc)

I experienced or witnessed a staff safety concern (unsafe lifting, co-worker got hurt, etc)

Other Other (Optional)

What happened? (please be as specific as possible, don’t violate HIPPA) (Optional)

Did you report this to your supervisor/Charge Nurse? (Optional)

Yes No

Did you fill out a Risk Connect (PVSR) Form? (Optional)

Yes No

What do you want to see happen now? (Optional)
What do you want to see happen now? is required.

I am documenting my concern to help show a pattern and the impact of staffing levels, no follow-up is needed at this time.

I want a union leader to help me report this or discuss options with me (please contact your union leader directly here. Union stewards/leaders will not respond to this form. (Link Below)

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Click Here to contact your union leader directly here. Union stewards/leaders will not respond to this form.

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