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Unsafe Staffing Form Examples 2022

Every day across Massachusetts, nurses take time to fill out unsafe staffing forms out of concern for the safety of their patients and the quality of their nursing practice. In 2022, nurses filled out more than 5,000 of these forms, from Berkshire Medical Center to Cape Cod Hospital and nearly every hospital in between. The Massachusetts Nurses Association has filed legislation to help address this problem. Below are examples of unsafe staffing forms from 2022 from across the Commonwealth, with identifying information about caregivers and patients not included or removed.


St. Elizabeth's Medical Center in Brighton

Emergency Room

June 7, 2022

7 p.m. to 7 a.m. shift

# of nurses on: 4

# of nurses needed: 6

Excerpt from form: