Reference no: EM131642440

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}.