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Home » Report an Unsafe Assignment or Workplace Safety Issue Form

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Report an Unsafe Assignment or Workplace Safety Issue Form

Your Health and Safety is AaNA’s Priority

Use this form to report an assignment that you believe is potentially unsafe for patients and/or staff, or other workplace safety concern. Completing this form allows you to advocate for your patients and protect yourself by formally documenting the situation and your actions. Your report also provides AaNA with data to support you, identify trends in unsafe assignments, and raise issues with management.

Fill out and submit the form online below. See below to submit a form offline.

Bargaining Unit* Providence Alaska Medical CenterCentral Peninsula Hospital and Heritage PlacePeaceHealth Ketchikan Medical Center

First Name*

Last Name*

Personal Email*

Personal Cell Phone*

Employee ID Number*

Date of Incident*

Time of Incident*

Issues*StaffingEquipment and SuppliesSystem FailureMissed Breaks and MealsWorkplace ViolenceWorkplace Injury or IllnessOther

Other issue

Please provide details about the incident you are reporting. When describing the incident, include details on unintended consequences to the patient (e.g. delayed medication, documentation) or to the nurse (e.g. no continuity of care, missed break, injury)*:

What unit/location were you at?*

What shift were you working?*

Census*

Number of patients assigned to you time?

Number of admissions to unit during shift?

Number of discharges during shift?

Number of transfers shift?

Number of RNs working at the time?

Number of LPNs working at the time?

Number of PCTs, CNAs working at the time?

Other staff working at the time?*

Actions Taken*I filed an incident report at workI notified a supervisorThis was resolved on my shiftOther

Other Actions Taken*

WHEN YOU SUBMIT THIS FORM, A COPY WILL BE SENT TO YOUR BARGAINING UNIT OFFICERS AND AaNA. YOU WILL ALSO RECEIVE A COPY OF THIS COMPLETED FORM.

How to Submit Your Form Offline

If you prefer, you may download a form and fill it out offline. This form should be submitted to AaNA. You should also keep a copy of this completed form. Fax your form to (907) 272-0292 or send it via email to ak*****@*****se.org.