OH&S Complaint Form

Workload – OH&S Complaint Form

Workload - OH&S Complaint Form

Reporter Name(Required)

First Last

Reporter Phone(Required)

Reporter Email(Required)

Date of Event

Supervisor/Manager in charge(Required)

Manager Phone

Region(Required)

Facility(Required)

Department(Required)

Number of persons not replaced(Required)

Number Of Shift Hours Not Replaced(Required)

Were you working short:

Yes

Were you short due to:

Absence

Vacancy

Sick Call

Staff Off Unit

Was overtime:

Approved

Offered

Unknown

Is there a work standard in place for working short (including do, defer, delegate, delete)

Yes

Unknown

Was an OH&S or W1 form filled out?(Required)

(If so, please keep a copy)

Yes

Was an OH&S form filled to include Client Safety form?(Required)

(If so, please keep a copy)

Yes

How did workload impact staff?

(stress, fatigue, missed breaks, injures/pain – physical and or psychological)

How did workload impact patients?

(quality of care, missed tx, late meds, cold meals)

Factors of workload

(equipment, untrained staff, pt concerns, staff/patient ratio, admissions, transfers, isolation)

Record ID Number (For Committee use)

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OH&S Complaint Form

Workload – OH&S Complaint Form

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