UWMC-Northwest CNA Short Staffing Form

Upon submitting this form, you will receive a copy of your answers in your email.
1. Forward a copy to your manager
2. Forward one copy to your unit’s delegate and/or union organizer.

My ability to provide quality patient care has been compromised because of the following (check or explain as needed):

In my professional judgment, today’s staffing assignment is unsafe and places our patients at risk. I will, under protest, attempt to carry out the assignment to the best of my ability.