Hospital Clinical Staffing Complaint Form

Have you filed a complaint with the hospital’s Clinical Staffing Committee?

Yes

If NO, you should first file a complaint with the hospital’s Clinical Staffing Committee prior to submitting this form. If you are unable to file a complaint with the hospital’s Clinical Staffing Committee, please provide a detailed description explaining why and continue with the submission of this form.

If YES, please answer the following questions:

Date on which the complaint was filed with the hospital’s Clinical Staffing Committee, if applicable:

Please provide the hospital complaint reference number associated with this complaint (if available):

Is this the first complaint you’ve filed with the hospital’s Clinical Staffing Committee regarding this particular issue?

Yes

If NO, including this complaint, how many complaints have you filed with the hospital’s Clinical Staffing Committee regarding this particular issue?

Has the hospital’s Clinical Staffing Committee completed a review of this complaint?

Yes

Unknown

If YES, what were the results of their review?

If YES, what were the results of their review

The hospital’s Clinical Staffing Committee created a specific action plan to address the issues raised in the complaint

The hospital’s Clinical Staffing Committee did not make any changes based on the complaint I filed

I did not receive a response from the Clinical Staffing Committee

Other (please specify):

Do you wish to remain anonymous to the hospital?

Yes

Contact Information

Providing information about you will allow Department staff to contact you should additional information be needed. It is our policy to keep your name confidential. It may be necessary to share the nature of your complaint or the patient's name with the facility. Please do not attach any additional information such as medical records, as it will not affect the outcome of the decision.

First Name

Last Name

Email Address

Daytime Phone

Street Address

City/Town

State/Province

ZIP/Postal Code

This is a complaint from:

Complaint type

An employee of the hospital [RN, LPN, Other licensed staff, Other unlicensed staff](Please specify below)

A union representative (Please specify below)

Patient

Member of the public

Other (describe)

Facility Information

Facility Information info

Facility Name

Facility Address

Name of Clinical Unit:

Choose an item.

Today's Date:

Additional information regarding clinical staffing concerns:

The ratio of RNs to patients is lower than provided in the hospital’s Clinical Staffing Plan posted on the Department’s website

The entire shift

More than half of the shift, but not the entire shift

Less than half of the shift

The ratio of RNs to patients is lower than in the Clinical Staffing Plan posted in the hospital for that shift on that unit

The entire shift

More than half of the shift, but not the entire shift

Less than half of the shift

There was no Clinical Staffing Plan posted in the hospital for that shift on that unit

The ratio of ancillary support staff to patients is lower than in the hospital’s Clinical Staffing Plan

The entire shift

More than half of the shift, but not the entire shift

Less than half of the shift

Staff that were absent or scheduled off were not replaced

The entire shift

More than half of the shift, but not the entire shift

Less than half of the shift

Missed meals and/or breaks due to insufficient staffing to provide coverage

Other, please describe below

Staffing Patterns at the time of incident:

Patient census at time of incident:

Number of RNs

Number of LPNs

Number of PCTs

Number of CNAs

Other

If the concerns identified above impacted care provided to a patient, please submit a complaint and provide additional information regarding the situation to: https://apps.health.ny.gov/surveyd8/email-hospdtc

Please provide any additional information about your complaint that you think would be helpful to share. Please include any additional descriptions of the items above, or any other information that you feel could provide additional context:

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Department of Health

Hospital Clinical Staffing Complaint Form

Department of Health

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Department of Health

Hospital Clinical Staffing Complaint Form

Department of Health

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Events

Current Issues

Help

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