Concern For Safe Staffing Form

The completed form will be submitted to your unit manager and VFNHP.

CFSS Forms serve as a means to:

  • Provide your supervisor an opportunity to correct an unsafe situation
  • Limit your personal and professional liability
  • Document trends in staffing, patient volume and/or acuity levels for your Unit Staffing Collaborative to collect, analyze for changes in the staffing plans.

No VFNHP member should be harassed, coerced, intimidated or discriminated against for signing a CFSS. Report any form of retaliation to VFNHP office immediately.

Step 1 of 2
IMPORTANT: Please do not include patient identifying information.
I have notified you that the staffing provided is not adequate to meet the needs of the patients on/in this unit/department at this time. Proper staffing has not been provided. Therefore, I am informing you that I am concerned in regards to any errors or incidents that take place as a result of the staffing level on this unit.

FAQs

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Call: (802) 657-4040

Fax: 802.871.5946

Email: info@vfnhp.org

Address: 96 Colchester Ave, Burlington VT 05401

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