Please complete part 2 of 2 before leaving the work setting at the end of the work period.
Supervisor: give this form to the supervisor who made the assignment or requested the conduct for which you are invoking safe harbor.
Signature: the nurse(s) invoking safe harbor must sign this form even if the supervisor completes the form in accordance with NPR Law §303.005(b-1) & (b-2).
Refusal: a supervisor's refusal to sign and/or accept a nurse's invocation documentation does not render the invocation invalid.
Page 2: only complete the following if the nurse(s) refuse(s) to engage in the requested conduct or assignment pending the safe harbor nursing peer review determination.
| Question | Answer |
|---|---|
| Form Name | BON Safe Harbor Quick Request Form |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 17 |
| Avg. time to fill out | 3 min |
| Edition | Revised 3/2020 |
| Where to send | Give it to your supervisor; do NOT fax or mail it to the BON |
| Other names | Safe Harbor Quick Request Form, BON Safe Harbor Quick Request Form, Safe Harbor form, nursing safe harbor |
| Official source | BON Safe Harbor Quick Request Form, Published 5/2008; Revised 3/2020 |
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