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Patient Safety Reporting Form (ADO)

January 11, 2023


By filing this form, you are complying with the law, protecting your hard-earned license and showing solidarity with your fellow Nurses and Healthcare Professionals. Most of all, you are actively advocating for your patients! This form will be sent to your Union. You may additionally send a copy to your supervisor to notify hospital administrators.

If you have questions about filling out this form or about your rights, contact your SEIU 121RN Union Rep/Organizer. You can find their contact info here.

If you are reporting on nurse-to-patient ratios, please review the correct ratios for your unit.

Observe HIPAA patient privacy when completing this form.

Be sure to document how you protested this assignment and alerted your supervisor.