This assessment should be done in any circumstance where in the professional judgement of the nurse, or nursing team, there is an inability to provide appropriate care for one or more health consumer/s. This includes but is not limited by the presence of one or more factors affecting safe practice in the Limits of Safe Practice Assessment.
Privacy Act 2020
The personal and health and safety information collected on this form may be used to facilitate safer staffing in the workplace.
This statement does not replace, and should be read in conjunction with, the privacy statements on the NZNO online joining form.
You are protected when raising a health and safety matter
It is illegal for the PCBU (i.e. your employer or their representative) to take discriminatory action against you or other workers for completing this assessment. Under the Health and Safety at Work Act 2015 you have protections from such conduct.
Please complete both Sections of this form
- Section 1 captures the formal assessment of the situation. On completion you will be sent a PDF file and an Edit link so you can return to complete Section 2.
- Section 2 captures what happens after your senior RN/MW is informed of the situation. On completion you will be sent a PDF link for the full report and an Edit link for any further updating.
Your NZNO Delegate and your Health and Safety Representative can review these Assessments and follow up with your senior RN/MW. You can also liaise with your local NZNO Organiser if further assistance and/or escalation is required.
If you have any questions or concerns, please contact us at firstname.lastname@example.org.