Concern For Safe Staffing Form








(A copy of the completed form will automatically be sent to the e-mail address you enter)






















(For example, a successful resolution might be that management responded to your action by adding more staff in a timely fashion, thus alleviating the unsafe staffing situation.)






(NOTE: The detailed explanation/narrative you write in this box will NOT be included on the hard copy of the form that you can print off and share with your supervisor after you hit "Submit." However, the detailed explanation/narrative you write in this box WILL be included in the electronic copy of this submission that is e-mailed to MNA and to yourself if you included your e-mail address on the form.)


(NOTE: This information regarding PR usage will NOT show up on the printed version of the form that you turn in to your supervisor.)