Concern For Safe Staffing Form


  1. Prior to using this form, you must notify the ANC/manager in person or by phone of your need for more help. This form is to document your request. If you didn’t make the request, you can’t use it.
  2. Use this form only if you don’t have adequate help. If these forms are used indiscriminately and without justification, it will dilute their usefulness.
  3. 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.



We are a strong union of health care professionals organized to ensure access to high-quality health care for everyone in the communities we serve.

Call: (802) 657-4040

Fax: 802.871.5946


Address: 96 Colchester Ave, Burlington VT 05401