Name *

First Name

Last Name

Phone *

(###)

###

####

Have you heard of the new safe staffing law? *

Yes

No

Has your hospital done anything around it? *

Yes

No

Do you ever feel unsafe at work because of low staffing? *

Yes

No

How often is your unit understaffed? *

Rarely

Some of the time

Most of the time

Have you ever ended your shift worried about the safety of your patients or potentially losing your license because of staffing conditions? *

No

Yes

In the past, when you or your colleagues have brought concerns about staffing to management, their response has been: *

Listened and made changes

Listened but unable to make changes

Did nothing

I have never brought my concerns to management

Concerned about speaking up for fear of losing my job

Does your hospital currently have a Staffing Committee in place? *

Yes

No

Staffing committees are charged with developing a staffing plan for the facility that is enforceable by law, including financial penalties for violations. Are you interested in participating in a staffing committee? *

Yes, sign me up!

I’m potentially interested and would like more information about what this would entail

No

Do you know what your unit’s safe staffing standard is? *

Yes

No

Not sure but would love to know where to find it.

Has your hospital posted the staffing plan and data in a public place on each unit, as required by law? *

Yes

It’s posted, but it’s not in a public place.

No

There are New York based organizations who are seriously fighting to enforce safe staffing laws for RNs. Would you like to receive updates on the progress they’ve made or invitations to future events? *

Yes, send me updates! By text, email or call

I’m potentially interested and would like more information

No