Type directly into the document and see attached
Type directly into the document and see attached
The Nurse’s Request for Safe Harbor must be made before accepting the assignment (including any point during the work period when the assignment changes) and the request MUST be made IN WRITING.                  DO NOT FAX OR MAIL THIS FORM TO THE BON
Minimum Required Information to Make Initial Request Invoking Safe Harbor
The following information must be in writing, but may be on any form and in any format provided it is in writing (includes electronic transmittals such as e-mail):
- Nurse(s) Name(s) invoking Safe Harbor;
- Date/Time of Request;
- Location of requested conduct/assignment;
- Name of person/supervisor making assignment or requesting the conduct;
- Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217.11 and 217.12.
- Document collaboration between nurse(s) and supervisor {always recommended; required if nurse(s) refuse assignment/conduct requested}.
REMEMBER TO COMPLETE COMPREHENSIVE REQUEST FOR SAFE HARBOR (SEE FORM) REQUIRED PRIOR TO THE END OF, OR BEFORE LEAVING THE WORK ASSIGNMENT AREA.
- Nurse(s) Name(s) invoking Safe Harbor:
- Date/Time of Request:
- Location of requested conduct/assignment:
- Name of person/supervisor (and title) making assignment or requesting the conduct:
- Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217.11 and 217.12):
Signature(s) of Nurse(s) Invoking Safe Harbor:
Signature of Supervisor/Person Making Assignment (Note: A supervisor’s refusal to sign this form does not render the nurse’s request for Safe Harbor invalid):
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The following portion of this form need be completed ONLY IF the nurse intends to refuse the requested assignment when invoking Safe Harbor.
- I(we) believe in good faith that I(we) cannot accept the assignment requested because (Mark the ONE Applicable Box Below):
- GÂ Â Â Â Â Â Â Â I(we) lack the basic knowledge, skills, and abilities necessary to competently perform the assignment. I(we) believe that engaging in the assignment/conduct requested pending peer review committee determination would expose one or more patients to an unjustifiable risk of harm.
On(date/time), the patient safety concern raised by the nurse(s) initiating safe harbor peer review was jointly reviewed with
, who is the supervisor who made the assignment.
Please provide a description of the resolution of the issue, or the rationale if unable to agree upon a safe assignment below (attach other pages as necessary):
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Name of Nurse(s) Initiating     Date/time                   Name of Supervisor         Date/time
- GÂ Â Â Â Â Â Â Â I(we) believe that the assignment or conduct requested would constitute unprofessional conduct under the BON statutes and rules, or criminal conduct such as fraud, theft, falsification of records, patient abuse or exploitation, etc. See Nursing Practice Act Section 301.452, BON Rule 217.12, and applicable BON Disciplinary Sanction Policies http://www.bon.state.tx.us/disciplinaryaction/dsp.html.
Any request for safe harbor, be it on this form or in any other written form or format, is subject to confidentiality requirements of NPA (TOC)
§303.006, §303.007, §303.0075, and Rule 217.20.
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Posted 17 Sep 2017 07:09 AM
My Price 10.00
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