Nursing Staff Dispatch Checklist Form
Complete this checklist to confirm assignment readiness and key shift details for a nurse being dispatched to a facility or patient care location.
Nurse's Full Name
*
First Name
Last Name
Destination Facility or Patient Location
*
Date and Time of Dispatch
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Shift Type
*
Please Select
Day
Evening
Night
On-Call
Other
Contact Number at Destination
*
Please enter a valid phone number.
Format: (000) 000-0000.
Assignment Confirmed with Facility/Location?
*
Yes
No
Required Equipment/Supplies Provided?
PPE Kit
Medical Bag
Identification Badge
Other
Special Instructions or Notes
Transportation Arranged?
*
Yes
No
Coordinator Name
*
First Name
Last Name
Complete Dispatch Checklist
Should be Empty: