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NAME
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UNIT/SITE
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Primary Shift Worked
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I work
What school (or schools) did you attend and/or currently attend?
What degree (or degrees) do you have?
cell/home phone:
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Preferred Contact Method:
Home email address
I have a schedule that follows contract guidelines.
My work area is appropriately staffed with nurses to provide quality and safe care for our patients.
There are an adequate number of regularly scheduled and trained support staff (LNAs, secretary, patient support, lift team) to provide safe and appropriate care for my patients.
Have you ever experienced an injury on the job due to insufficient staffing or lack of proper equipment?
Does the nurse-patient ratio provided in your unit/site staffing grid meet the patients' acuity needs?
In the past two years, have you been put in a situation at work where you did not feel safe?
My area provides me with adequate time and opportunity to pursue continuing education necessary to provide safe care for our patients using best practice.
Are you able to obtain conference time for educational opportunities in your area of work?
I accrue enough CTO hours to be able to cover vacation time and sick days for myself, as well as the time I may need to care for a sick family member.
In the past two years, my manager has been able to provide me with requested CTO time off.
Our current retirement plan will allow me to live comfortably when I retire.
Have you put off retirement because of concerns regarding health care insurance?
What percentage of pay increase do you need to meet your financial obligations in addition to your 2% step increase?
Please respond with what additional dollar amount or percentage of pay should you receive as Charge Nurse.
If this doesn't apply to your site, respond N/A
Please respond with what additional dollar amount or percentage of pay should you receive as Preceptor.
If this doesn't apply to your site, respond N/A
Please respond with what dollar amount or percentage of pay you should receive for shift differential for EVENING SHIFT:
If this doesn't apply to your site, respond N/A
Please respond with what dollar amount or percentage of pay you should receive for shift differential for NIGHT SHIFT:
If this doesn't apply to your site, respond N/A
Please respond with what dollar amount or percentage of pay you should receive for shift differential for WEEKEND SHIFT:
If this doesn't apply to your site, respond N/A
Please respond with what dollar amount or percentage of pay you should receive for shift differential for ON CALL SHIFT:
If this doesn't apply to your site, respond N/A
Do you support pay equity for Outpatient Nurses?
Are you willing to strike to achieve a contract that improves our lives as well as those of our patients?
Briefly describe something in the current contract or a company policy that is a source of frustration or confusion for yourself and/or your colleagues.
Please provide any comments you would like to share with us.
