• Safe Staffing Next Shift Assessment

  • To the senior RN/MW responsible for staffing:

    This safe staffing assessment is to inform you that due to an identified potential Acute Staffing Shortage on the next shift, an unsafe work situation may occur if effective control measures are not implemented.

    These measures will need to address the predicted negative shift variance and/or other factors which reflect the workload, health consumer acuity, skill mix and the workers available.

    If the staffing shortfall is not adequately addressed, a worker or workers may breach their Limits of Safe Practice.

    The measures taken or not taken may also affect provision of safe and competent care to health consumers.

  • To the worker completing this form:

    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.

  • A copy of this form will be emailed to safestaffing@nzno.org.nz.

  • THIS shift: Staffing situation

  •  - -
  • THIS shift: Variance situation

  • If you have not already done so, please complete a Limits of Safe Practice Assessment.

  • NEXT shift: Staffing situation

  •  - -
  • NEXT shift: Known staffing shortfalls

  • NEXT shift: Anticipated shortfall of other support roles

  • NEXT shift: Expected conditions

  • Time-stamp and declaration

  •  - -
  • I declare that I have completed this Safe Staffing Next Shift assessment in good faith, and that to the best of my knowledge and ability, the forecast information provided is accurate as was possible to determine at the time of completion.

  • Once you have submitted this form it cannot be amended.

    When you are ready, click the Submit button to receive an email which contains a printable PDF of this Assessment for your records

    Then print out the PDF and provide a copy to:

    • Senior RN/MW or other manager as necessary
    • The NEXT shift coming on-duty so are aware of the safety concerns raised.

    A copy of this form will be emailed to safestaffing@nzno.org.nz. The information will be reviewed by your local NZNO Organiser and stored for use as needed with the escalation pathway process.

    Thank you very much for taking the time to complete this Assessment. You're helping to make your workplace safer for yourself and your colleagues.

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