Nurse Shift Start Check-in Form
Please complete this form at the start of your shift to confirm your readiness for duty.
Full Name
*
First Name
Last Name
Employee ID Number
*
Date of Shift
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Assigned Unit/Department
*
Please Select
Emergency
Intensive Care Unit (ICU)
Medical/Surgical
Pediatrics
Maternity
Operating Room
Other
Are you wearing your full uniform and required identification badge?
*
Yes
No
Do you have all necessary equipment and supplies for your shift?
*
Yes
No (please specify below)
How do you feel today regarding your health and fitness for duty?
*
Fit and ready for duty
Mild issues, but able to work
Not fit for duty (please notify supervisor)
Have you received the shift handover/briefing?
*
Yes
No
Please list any immediate concerns, issues, or missing supplies (if any)
Check In
Should be Empty: