File A UAF

Unsafe Assignment Form

Collective Bargaining Members Use ADO Form

Report Unsafe Conditions – Document an Unsafe or Inadequate Situation

The Ohio Nurses Association is sounding the alarm on unsafe conditions. Submit an Unsafe Assignment Form to document an unsafe or inadequate situation. Upon submission, you will receive a copy via your email, and ONA will receive a copy. ONA will use the submitted data in our ongoing advocacy work to make healthcare in Ohio safer for all. Personal identifiers will never be shared publicly or with employers.

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"*" indicates required fields

Your Employer*

Unit*

Unit where the incident occurred

What is the issue you'd like to report?*

Select all that apply.

Workplace Violence

Understaffing

Unsafe Conditions and Safety Concerns

Inadequate Equipment / Supplies

Missed Breaks & Denied Earned Time

Breastfeeding / Pumping

Workplace Violence

Who was the perpetrator:*

Patient

Visitor

Other

Type of WPV:*

Select all that apply

Verbal threats or abuse

Harassment

Intimidation

Disruptive behavior

Unwanted sexual advances

Verbal or physical conduct of sexual nature

Attempted or actual physical assault with or without a weapon including bodily fluids

Was medical treatment required?*

Yes

Was there destruction of personal property?*

Yes

Describe the destroyed property:*

Was a police report filed?*

Yes

Were you discouraged from filing a police report?*

Yes

I was discouraged because:*

Select all that apply

I did not think reporting would make a difference

I was afraid to report

I was discouraged by my employer

I was told the police wouldn't be willing to make a report

Other (place in comment box at end of form)

Understaffing

Understaffing Issue:*

Select all that apply.

Charge with assignment/unable to perform charge duties

Short staffed for census/ acuity/ complexity

Not trained/ experienced/ oriented to area assigned or floated

All roles of the care team not fully staffed

Floating to multiple units during shift

Forced/ mandatory OT

No clerk/ secretary

Unsafe Conditions and Safety Concerns

Unsafe Condition or Safety Concern:*

Select all that apply.

Unavailable PPE

Denied available PPE

Infectious patient(s) not properly isolated

Failure to test patients meeting signs/ symptoms

Visitor Policy not enforced

Facilities Issues

Inadequate Equipment / Supplies

Inadequate Equipment / Supplies:*

Select all that apply.

Unavailable/Missing

Substandard

Needs specialized equipment

Not trained/experienced to use equipment

Medication dispensing machine

Medication bar coder

Computers

Missed Breaks & Denied Earned Time

Missed breaks & Denied Earned Time:*

Select all that apply.

Missed Meal or Rest Breaks

Denied Earned Time: This includes vacation, PTO, Sick, Extended Illness, Education leave

Forced to Work when Sick

Breastfeeding / Pumping

Breastfeeding / Pumping:*

Select all that apply.

Delayed break time

Denied break time

Inadequate space provided including: not shielded from view, not free from intrusion of coworkers or public, space was a bathroom, or space not sanitary

Additional Information

Additional Comments: Please provide additional information while maintaining HIPAA standards.

First Name*

Last Name*

Phone Number

Personal Email*

I hereby object to the assignment as made to me by:*

*List the manager, assistant manager, or house supervisor on duty, NOT the charge person

Date incident occurred*

MM slash DD slash YYYY

9. Shift:*

Select the shift where the majority of your hours were worked

Day shift

Night shift

Role:*

Your Role*

RN Information

As a Registered Nurse, I advocate for the safest possible care and work environments. I am documenting an unsafe or inadequate assignment in an effort to protect healthcare workers and patients by contributing to the body of evidence of the frequency and type of unsafe situations occurring in Ohio hospitals and healthcare facilities.

LPN Information

As a Licensed Practical Nurse, I advocate for the safest possible care and work environments. I am documenting an unsafe or inadequate assignment in an effort to protect healthcare workers and patients by contributing to the body of evidence of the frequency and type of unsafe situations occurring in Ohio hospitals and healthcare facilities.

Surgical Tech Information

As a Surgical Tech, I advocate for the safest possible care and work environments. I am documenting an unsafe or inadequate assignment in an effort to protect healthcare workers and patients by contributing to the body of evidence of the frequency and type of unsafe situations occurring in Ohio hospitals and healthcare facilities.

Respiratory Therapist Information

As a Respiratory Therapist, I advocate for the safest possible care and work environments. I am documenting an unsafe or inadequate assignment in an effort to protect healthcare workers and patients by contributing to the body of evidence of the frequency and type of unsafe situations occurring in Ohio hospitals and healthcare facilities.

Other

As a health professional, I advocate for the safest possible care and work environments. I am documenting an unsafe or inadequate assignment in an effort to protect healthcare workers and patients by contributing to the body of evidence of the frequency and type of unsafe situations occurring in Ohio hospitals and healthcare facilities.