Healthcare Staffing Ratio Waiver Request Form
Submit a request for an exception to standard staffing ratios for operational review.
Requester Name
*
First Name
Last Name
Contact Email
*
example@example.com
Facility Name
*
Department or Unit
*
Shift or Date for Requested Waiver
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Staffing Ratio (e.g., 1:5)
*
Requested Staffing Ratio (e.g., 1:7)
*
Reason for Waiver Request
*
Patient Safety Impact and Mitigation Plan
*
Duration of Waiver (number of days or specific dates)
*
Submit Waiver Request
Should be Empty: