Safe Staffing Form - Degraff Medical Park

DeGraff Staffing Report

What is your unit/department?

2. Date on which the shift started: *This question is required.

3. Time for which you are reporting staffing:
Use 24-hour (military time) format, for example 0230 for 2:30am. *This question is required.

4. Shift for which you are reporting staffing: *This question is required.

5. Total Number of Patients on Unit: *This question is required. This question requires a valid number format.

Number of Emergency Department Staff on Duty:
(Please exclude staff that are currently being oriented or trained or who are unable to take a full assignment) *This question is required.

Charge RN
RN
PCA

Number of SNF 1 Staff on Duty:
(Please exclude staff that are currently being oriented or trained or who are unable to take a full assignment) *This question is required.

RN
LPN
CNA
Clerical

Number of SNF 2 Staff on Duty:
(Please exclude staff that are currently being oriented or trained or who are unable to take a full assignment) *This question is required.

RN
LPN
CNA
Clerical

I need to report information for a job title that is not listed

Number of Staff on Duty *This question is required.

Space Cell	Job Title	# of Staff on Duty
	: Job Title	: # of Staff on Duty
	: Job Title	: # of Staff on Duty
	: Job Title	: # of Staff on Duty
	: Job Title	: # of Staff on Duty
	: Job Title	: # of Staff on Duty