Safe Harbor Form – Fill Out and Use This PDF

Texas Board of Nursing

SAFE HARBOR QUICK REQUEST FORM

{Remember to Complete Comprehensive Form/Information on Same Day}

Published May 2008 (rev. 9/08)

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):

1.Nurse(s) Name(s) invoking Safe Harbor;

2.Date/Time of Request;

3.Location of requested conduct/assignment;

4.Name of person/supervisor making assignment or requesting the conduct;

5.Brief explanation of why invoking Safe Harbor (It may be helpful to review rules 217.11 and 217.12.

6.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.

1.Nurse(s) Name(s) invoking Safe Harbor:

____________________________________________________________________________

____________________________________________________________________________

___________________________________________________________________

2.Date/Time of Request: ____________________________________________________

3.Location of requested conduct/assignment:____________________________________

_________________________________________________________________________

4.Name of person/supervisor (and title) making assignment or requesting the conduct:

_________________________________________________________________________

5.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): ____________________

__________________________________________________________________________

The following portion of this form need be completed ONLY IF the nurse intends to REFUSE the

requested assignment when invoking Safe Harbor.

A mutual collaborative effort between the nurse(s) and supervisor making the assignment is required by Rule 217.20(g)(2) when the nurse refuses to engage in the requested conduct/assignment pending determination by the safe harbor peer review committee (SHPRC) because the nurse believes the assignment is not within the individual nurse’s scope of practice.

If the conduct requested would constitute unprofessional or criminal conduct, collaboration between the nurse and supervisor is not required, however, any alternative assignment or conduct requested by the supervisor must not require the nurse to engage in unprofessional or criminal conduct.

6.I(we) believe in good faith that I(we) cannot accept the assignment requested because (Mark the ONE Applicable Box Below):

(A)G 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):

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

_______________________________	___________________________
Name of Nurse(s) Initiating Date/time	Name of Supervisor	Date/time

(B)G 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.

REMEMBER TO COMPLETE COMPREHENSIVE REQUEST FOR SAFE HARBOR (SEE FORM) REQUIRED PRIOR TO THE END OF, OR BEFORE LEAVING THE WORK ASSIGNMENT AREA.

KEEP A COPY OF BOTH REQUESTS