Nurse Staffing Plan Arbitration Request Form

Nurse Staffing Plan Arbitration Request Form

Use this form to notify OHA to initiate the arbitration process. This form is only for Nurse Staffing Plans.

Under ORS 441.766, the only Nurse Staffing Plans eligible for arbitration are those for which there are exceptions to direct care registered nurse-to-patient staffing ratios:

Patients in intensive care or critical units in circumstances prescribed by the hospital nurse staffing committee;
Emergency department patients who are in critical condition, until they are stable;
Patients in swing beds, as defined by the Centers for Medicare and Medicaid Services;
Patients, in inpatient units, who are ready for discharge but are facing a barrier to discharge, as indicated by a licensed independent practitioner in each patient's medical record;
Patients, including patients in an emergency department, who are located in adjacent rooms or the same room in the hospital and who are ready for discharge but are facing a barrier to discharge, as indicated by a licensed independent practitioner in each patient's medical record;
Patients in outpatient units that operate under a hospital's license; or
Patients in psychiatric units.

Professional/Technical Staffing Plans and Service Staffing Plans are not eligible for arbitration.

Name of person completing this form*

Title of person completing this form*

Email of person completing this form*

Phone of person completing this form*

Phone

Hospital

Select

Date Nurse Staffing Committee Co-Chair invoked 60-day deliberation period*

Date 60-day deliberation period ended*

Did the Nurse Staffing Committee extend the 60-day deliberation period?*

If by the end of the first 60-day period, the hospital Nurse Staffing Committee does not adopt a Nurse Staffing Plan, the members of the committee may extend deliberations for one additional 60-day period by a majority vote of the members of the committee.

Yes

Date second 60-day deliberation ended*

List the disputed Nurse Staffing Plan(s) below*

For each Nurse Staffing Plan under dispute, include unit(s) the Nurse Staffing Plan covers.

Upload the Nurse Staffing Plan(s) or part(s) of the Nurse Staffing Plan under dispute*

Upload ALL Nurse Staffing Plans under dispute as a single file

Drag and drop files here or

Send me a copy of my responses

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