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GRACE HOSPITAL WORK OVERLOAD FORM Department/Unit Department/Unit: /Unit: _____________ _______________________________ _____________________ 1) Date of work overload occurred: ___ / ___ ___ / ___ (DD/MM/YY) ( __ Day __ Evening __ Night __ 12hr Day __ 12hr Night 2) Time and duration of Heavy Workload: Workload: _____hrs to _____hrs Total time _______hrs 3) Staffing a) Number of Staff scheduled for this shift: AIDES _____ RN ______ LPN ______ CLERK_____ b) Normal number of staffing for this shift: AIDES _____ RN ______ LPN ______ CLERK_____ 4) Contributing Contributing factor to the situation: (Check ALL that applies) __ Insufficient Staff __ Unfamiliar Float/Casual __ High Acuity __ Lack of Equipment __ Lack of Supplies __ Discharges (#_____) __ Other/Unsafe work_________________________________ ______________________________________________ Please specify

5) Working conditions: (Check ALL that applies)

Meal Period __ Missed __ Late Breaks __ Missed __ Late Overtime __ Yes __ No If Yes, did the overtime remedy the situation? ______________________________________________ ______________________________________________ ______________________________________________


CUPE 1599 WORK OVERLOAD FORM

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6) Availability of Alternatives: a) Who did you inform of the situation? ____________________ Time: _____________ b) Did the individual with whom you discussed the situation visit the area? __ Yes __ No __ N/A c) Was additional staff made available? __ Yes __ No __ N/A d) Did additional staff need orientation? __ Yes __ No __ N/A __ Yes __ No __ N/A e) Was the additional staff helpful? If No, why not? _______________________________________ ____________________________________________________ ____________________________________________________ f) If no additional staff available, was there an attempt to redistribute the workload? __ Yes __ No If No, why not? _______________________________________ ____________________________________________________ ____________________________________________________ If Yes, was it helpful? __________________________________ ____________________________________________________ ____________________________________________________ SIGNATURES Names

Names

1_______________________ 2_______________________ 3_______________________ 4_______________________ 5_______________________

6_______________________ 7_______________________ 8_______________________ 9_______________________ 10______________________

Upon completion, please forward a copy to the Local Office, c/o CUPE Mail Room Room Or hand in forms forms to any CUPE Representatives/Executives in your area. For form refills: Notify CUPE Reps.


cupe heavy work overload