Under the MN Nurse Practice Act, you are obligated to advocate for your patients in situations that may threaten their safety. If you have a situation where you feel that unsafe staffing is a concern in your facility, please report it to the appropriate manager/supervisor/administrator at the time that it occurs.

MNA also provides you an opportunity to fill out Concern for Safe Staffing forms. These forms are used to:

You may choose to provide this form to your manager/supervisor/administrator or not. The important thing is that you vigorously advocate for safe staffing by reporting unsafe situations to the appropriate manager/supervisor/administrator at the time it occurs.

When filling out this form, please be sure to maintain the privacy of your patients by leaving out specific identifying data and specific patient diagnoses and actions.

Thank you for taking the time to document your nursing advocacy.

List the name(s) of any other MNA member(s) who assisted you.

A copy of the completed form will automatically be sent to the e-mail address you enter.
Please do not use your work provided email addresses.



(unlicensed assistive personnel)


(unlicensed assistive personnel)


(unlicensed assistive personnel)

If you did not receive help what action(s) did you take or will you take to continue to advocate for your patients? (choose all that apply)

Additional action taken to advocate for patient safety and assist others in doing the same: (choose all that apply)

NOTE: For HIPAA purposes the detailed explanation/narrative you write in the "others" fields will NOT be included on the hard copy of the form that you can print off and share with your supervisor after you hit "Submit." However, the detailed explanation/narrative you write in the "others" fields WILL be included in the electronic copy of this submission that is e-mailed to MNA and to yourself if you included your e-mail address on the form.