Heavy Workload Submissions - Health Care Workers Union

Heavy Workload Submission

Your Name

Your Personal Email

Your Phone Number:

Your Job Title:

Your Department:

Date of Inicdent:

Approximate Time of Incident:

Location of Incident:

Supervisor / Charge Nurse / Manager:

Was Someone Sick or Absent and Not Replaced?

Yes No

Was Someone on Vacation and Not Replaced?

Yes No

Explain in Detail What Caused An Increased to Your Workload:

Was Patient Care, Safety, or Service Affected?

Yes No

If Yes, How:

Other CUPE Member(s) Working at The Same Time That Share Concerns (NAME and PHONE NUMBER):

Was Any Other CUPE Member(s) Pulled and/or Relocated to Other Departments During Your Shift?

Yes No

If YES, Please Provide Further Details:

Did You Mention The Heavy Workload to Your Supervisor?

Yes No

If Yes, To Whom:

How Did They Respond:

Shall CUPE Forward This Heavy Workload Report to Your Supervisor?

Yes No

Supervisor / Charge Nurse / Manager Email