GENERAL INFORMATION (PLEASE PRINT) Sample Clauses
GENERAL INFORMATION (PLEASE PRINT). Location/Unit __ __ ____ Names of employee(s) reporting Date of Occurrence Shift D / E / N Time: ----- Name of supervisor first contacted about the incident, and when Please provide details about the working conditions at the time ofthe occurrence by providing the following information: Actual staffing - RNs # Actual staffing - RPNs # Actual staffing - USTs # Actual staffing - Allied # Float Pool - RNs # Float Pool - RPNs # Float Pool - UST # Central Therapy - Allied # RNs working overtime # RPNs working overtime # Other staff (PCA, agency) # Normal staffing - RNs # Normal staffing - RPNs # Normal staffing - USTs # (specify) Normal staffing - Allied # Admin/Unit Clerk? Yes D No D (specify) If there was a shortage of staff at the time of the occurrence please check the applicable box(es). D Leave / Vacation D Sick call (s) D Vacancies D Other
GENERAL INFORMATION (PLEASE PRINT). If accepted, my membership will be: (please select the category) Individual 1 Yr. Membership Individual 2 yr. Membership Family 1 Yr. Membership Family 2 yr. Membership Applicants Name Birth Date Spouse’s Name Birth Date Street Address City, State & Zip Telephone (home) Telephone (work) Cell Number E-Mail Address Unmarried children under the age of 19 and FULL-TIME college students under the age of 23. 1.
GENERAL INFORMATION (PLEASE PRINT). Location/Unit Names of employee(s) reporting Date of Occurrence Name of supervisor first contacted about the incident, and when