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<form class="jotform-form" action="https://submit.jotformpro.com/submit/41615880386966/" method="post" name="form_41615880386966" id="41615880386966" accept-charset="utf-8">
<input type="hidden" name="formID" value="41615880386966" />
<div class="form-all">
<ul class="form-section page-section">
<li class="form-line form-line-column form-col-1" data-type="control_image" id="id_141">
<div id="cid_141" class="form-input-wide">
<img alt="" class="form-image" border="0" src="//www.jotform.com/uploads/cramerf/form_files/university-of-iowa-hospitals-and-clinics-logo.png" height="70" width="180" />
</div>
</li>
<li class="form-line form-line-column form-col-2" data-type="control_text" id="id_152">
<div id="cid_152" class="form-input-wide">
<div id="text_152" class="form-html">
<p><span style="font-size:16px;"><strong>DEPARTMENT OF RESPIRATORYCARE <br />FORM TO ADDRESS STAFFING CONCERNS</strong></span></p>
</div>
</div>
</li>
<li class="form-line" data-type="control_text" id="id_166">
<div id="cid_166" class="form-input-wide">
<div id="text_166" class="form-html">
<p><strong>Instructions for completing form: </strong></p>
<p>Please select applicable choices and navigate through the form.</p>
<p><strong>*Staff should NOT include specific patient health information in their response to avoid HIPPA violation.</strong></p>
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</div>
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<li class="form-line jf-required" data-type="control_radio" id="id_132">
<label class="form-label form-label-top form-label-auto" id="label_132" for="input_132">
Please select your division
<span class="form-required">
*
</span>
</label>
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<div class="form-multiple-column" data-columnCount="4">
<span class="form-radio-item">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_132_0" name="q132_pleaseSelect132" value="Clinical" />
<label id="label_input_132_0" for="input_132_0"> Clinical </label>
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<span class="form-radio-item">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_132_1" name="q132_pleaseSelect132" value="Adult Dx" />
<label id="label_input_132_1" for="input_132_1"> Adult Dx </label>
</span>
<span class="form-radio-item">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_132_2" name="q132_pleaseSelect132" value="Peds Dx" />
<label id="label_input_132_2" for="input_132_2"> Peds Dx </label>
</span>
<span class="form-radio-item">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_132_3" name="q132_pleaseSelect132" value="Hyperbaric Medicine" />
<label id="label_input_132_3" for="input_132_3"> Hyperbaric Medicine </label>
</span>
</div>
</div>
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<div id="cid_170" class="form-input-wide jf-required">
<div style="width:100%; text-align:Left;">
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<li class="form-line form-line-column form-col-1 jf-required" data-type="control_dropdown" id="id_135">
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Unit.............................
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*
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<option value="RSCU"> RSCU </option>
<option value="Burn Unit"> Burn Unit </option>
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<option value="2JCP"> 2JCP </option>
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Date of Concern
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*
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<span class="form-sub-label-container" style="vertical-align: top">
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&nbsp;-
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</span>
<span class="form-sub-label-container" style="vertical-align: top">
<input class="form-textbox validate[required]" id="day_137" name="q137_dateOf137[day]" type="tel" size="2" maxlength="2" value="" />
<span class="date-separate">
&nbsp;-
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<label class="form-sub-label" for="day_137" id="sublabel_day" style="min-height: 13px;"> Day </label>
</span>
<span class="form-sub-label-container" style="vertical-align: top">
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<label class="form-sub-label" for="input_137_pick" style="min-height: 13px;"> </label>
</span>
</div>
</li>
<li class="form-line form-line-column form-col-3 jf-required" data-type="control_time" id="id_138">
<label class="form-label form-label-top" id="label_138" for="input_138">
Time of Concern
<span class="form-required">
*
</span>
</label>
<div id="cid_138" class="form-input-wide jf-required">
<span class="form-sub-label-container" style="vertical-align: top">
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<option value="0"> 0 </option>
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<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
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&nbsp;:
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<option value="50"> 50 </option>
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<label class="form-sub-label" for="input_138_minuteSelect" id="sublabel_minutes" style="min-height: 13px;"> Minutes </label>
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<div id="cid_171" class="form-input-wide jf-required">
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Supvr at time of concern
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*
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<option value="Brown, Jennifer"> Brown, Jennifer </option>
<option value="Endahl, Eric"> Endahl, Eric </option>
<option value="Hanken, Sue"> Hanken, Sue </option>
<option value="Hein, Ralph"> Hein, Ralph </option>
<option value="Holder, Mike"> Holder, Mike </option>
<option value="Kelchen, Jacque"> Kelchen, Jacque </option>
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<option value="Lock, Shawna"> Lock, Shawna </option>
<option value="Mellecker, Lynn"> Mellecker, Lynn </option>
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<option value="Rohwedder, Scott"> Rohwedder, Scott </option>
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Date Supervisor notified
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*
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&nbsp;-
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Time Supervisor notified
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*
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<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
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Shift
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*
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</li>
<li class="form-line jf-required" data-type="control_textarea" id="id_57">
<label class="form-label form-label-top form-label-auto" id="label_57" for="input_57">
Name(s) of staff with concern(s)
<span class="form-required">
*
</span>
</label>
<div id="cid_57" class="form-input-wide jf-required">
<textarea id="input_57" class="form-textarea validate[required]" name="q57_namesOf" cols="40" rows="2"></textarea>
</div>
</li>
<li class="form-line" data-type="control_widget" id="id_174">
<div id="cid_174" class="form-input-wide jf-required">
<div style="width:100%; text-align:Left;">
<iframe onload="widgetFrameLoaded(174)" frameborder="0" scrolling="no" allowTransparency="true" class="custom-field-frame" id="customFieldFrame_174" src="" style="border:none;width:600px; height: 7px;">
</iframe>
<div class="widget-inputs-wrapper">
<input id="input_174" class="form-hidden form-widget" type="hidden" name="q174_clickTo174" value="" />
<input id="widget_settings_174" class="form-hidden form-widget-settings" type="hidden" value="%5B%7B%22name%22%3A%22height%22%2C%22value%22%3A%22height%22%7D%2C%7B%22name%22%3A%22style%22%2C%22value%22%3A%22solid%22%7D%2C%7B%22name%22%3A%22color%22%2C%22value%22%3A%22%23ffcc00%22%7D%2C%7B%22name%22%3A%22spaceAbove%22%2C%22value%22%3A%22spaceAbove%22%7D%2C%7B%22name%22%3A%22spaceBelow%22%2C%22value%22%3A%22spaceBelow%22%7D%2C%7B%22name%22%3A%22horizontalSpace%22%2C%22value%22%3A%22horizontalSpace%22%7D%5D" data-version="2" />
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</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_checkbox" id="id_147">
<label class="form-label form-label-top form-label-auto" id="label_147" for="input_147">
In my/our professional opinion, these concerns were based on (check all that apply):
<span class="form-required">
*
</span>
</label>
<div id="cid_147" class="form-input-wide jf-required">
<div class="form-single-column">
<span class="form-checkbox-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_147_0" name="q147_inMyour147[]" value="Lack of training or experience in area assigned" />
<label id="label_input_147_0" for="input_147_0"> Lack of training or experience in area assigned </label>
</span>
<span class="form-checkbox-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_147_1" name="q147_inMyour147[]" value="Unit is staffed with staff not familiar with unit/ wrong skill mix" />
<label id="label_input_147_1" for="input_147_1"> Unit is staffed with staff not familiar with unit/ wrong skill mix </label>
</span>
<span class="form-checkbox-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_147_2" name="q147_inMyour147[]" value="Lack of adequate staff for acuity (short-staffed)" />
<label id="label_input_147_2" for="input_147_2"> Lack of adequate staff for acuity (short-staffed) </label>
</span>
<span class="form-checkbox-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_147_3" name="q147_inMyour147[]" value="Patient should be in a critical care unit with appropriate critical care staffing" />
<label id="label_input_147_3" for="input_147_3"> Patient should be in a critical care unit with appropriate critical care staffing </label>
</span>
<span class="form-checkbox-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="checkbox" class="form-checkbox validate[required]" id="input_147_4" name="q147_inMyour147[]" value="Admission or Transfers without additional help" />
<label id="label_input_147_4" for="input_147_4"> Admission or Transfers without additional help </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_textbox" id="id_150">
<label class="form-label form-label-top form-label-auto" id="label_150" for="input_150"> Other (please explain) </label>
<div id="cid_150" class="form-input-wide jf-required">
<input type="text" class=" form-textbox" data-type="input-textbox" id="input_150" name="q150_otherplease150" size="100" value="" />
</div>
</li>
<li class="form-line" data-type="control_widget" id="id_175">
<div id="cid_175" class="form-input-wide jf-required">
<div style="width:100%; text-align:Left;">
<iframe onload="widgetFrameLoaded(175)" frameborder="0" scrolling="no" allowTransparency="true" class="custom-field-frame" id="customFieldFrame_175" src="" style="border:none;width:600px; height: 7px;">
</iframe>
<div class="widget-inputs-wrapper">
<input id="input_175" class="form-hidden form-widget" type="hidden" name="q175_clickTo175" value="" />
<input id="widget_settings_175" class="form-hidden form-widget-settings" type="hidden" value="%5B%7B%22name%22%3A%22height%22%2C%22value%22%3A%22height%22%7D%2C%7B%22name%22%3A%22style%22%2C%22value%22%3A%22solid%22%7D%2C%7B%22name%22%3A%22color%22%2C%22value%22%3A%22%23ffcc00%22%7D%2C%7B%22name%22%3A%22spaceAbove%22%2C%22value%22%3A%22spaceAbove%22%7D%2C%7B%22name%22%3A%22spaceBelow%22%2C%22value%22%3A%22spaceBelow%22%7D%2C%7B%22name%22%3A%22horizontalSpace%22%2C%22value%22%3A%22horizontalSpace%22%7D%5D" data-version="2" />
</div>
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</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textarea" id="id_149">
<label class="form-label form-label-top form-label-auto" id="label_149" for="input_149">
Brief description of assignment and problem
<span class="form-required">
*
</span>
</label>
<div id="cid_149" class="form-input-wide jf-required">
<textarea id="input_149" class="form-textarea validate[required]" name="q149_briefDescription149" cols="70" rows="6"></textarea>
</div>
</li>
<li class="form-line" data-type="control_widget" id="id_176">
<div id="cid_176" class="form-input-wide jf-required">
<div style="width:100%; text-align:Left;">
<iframe onload="widgetFrameLoaded(176)" frameborder="0" scrolling="no" allowTransparency="true" class="custom-field-frame" id="customFieldFrame_176" src="" style="border:none;width:600px; height: 7px;">
</iframe>
<div class="widget-inputs-wrapper">
<input id="input_176" class="form-hidden form-widget" type="hidden" name="q176_clickTo176" value="" />
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</div>
</div>
</li>
<li class="form-line" data-type="control_textarea" id="id_162">
<label class="form-label form-label-top form-label-auto" id="label_162" for="input_162"> Please include any additional comments and/or any suggestions you have regarding how similar situations can be prevented in the future. </label>
<div id="cid_162" class="form-input-wide jf-required">
<textarea id="input_162" class="form-textarea" name="q162_pleaseInclude162" cols="70" rows="6"></textarea>
</div>
</li>
<li class="form-line" data-type="control_widget" id="id_177">
<div id="cid_177" class="form-input-wide jf-required">
<div style="width:100%; text-align:Left;">
<iframe onload="widgetFrameLoaded(177)" frameborder="0" scrolling="no" allowTransparency="true" class="custom-field-frame" id="customFieldFrame_177" src="" style="border:none;width:600px; height: 7px;">
</iframe>
<div class="widget-inputs-wrapper">
<input id="input_177" class="form-hidden form-widget" type="hidden" name="q177_clickTo177" value="" />
<input id="widget_settings_177" class="form-hidden form-widget-settings" type="hidden" value="%5B%7B%22name%22%3A%22height%22%2C%22value%22%3A%22height%22%7D%2C%7B%22name%22%3A%22style%22%2C%22value%22%3A%22solid%22%7D%2C%7B%22name%22%3A%22color%22%2C%22value%22%3A%22%23ffcc00%22%7D%2C%7B%22name%22%3A%22spaceAbove%22%2C%22value%22%3A%22spaceAbove%22%7D%2C%7B%22name%22%3A%22spaceBelow%22%2C%22value%22%3A%22spaceBelow%22%7D%2C%7B%22name%22%3A%22horizontalSpace%22%2C%22value%22%3A%22horizontalSpace%22%7D%5D" data-version="2" />
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</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_radio" id="id_163">
<label class="form-label form-label-top form-label-auto" id="label_163" for="input_163">
Do you desire a meeting with manager and/or supervisor to address your concerns?
<span class="form-required">
*
</span>
</label>
<div id="cid_163" class="form-input-wide jf-required">
<div class="form-single-column">
<span class="form-radio-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_163_0" name="q163_doYou" value="Yes" />
<label id="label_input_163_0" for="input_163_0"> Yes </label>
</span>
<span class="form-radio-item" style="clear:left;">
<span class="dragger-item">
</span>
<input type="radio" class="form-radio validate[required]" id="input_163_1" name="q163_doYou" value="No" />
<label id="label_input_163_1" for="input_163_1"> No </label>
</span>
</div>
</div>
</li>
<li class="form-line" data-type="control_widget" id="id_178">
<div id="cid_178" class="form-input-wide jf-required">
<div style="width:100%; text-align:Left;">
<iframe onload="widgetFrameLoaded(178)" frameborder="0" scrolling="no" allowTransparency="true" class="custom-field-frame" id="customFieldFrame_178" src="" style="border:none;width:600px; height: 7px;">
</iframe>
<div class="widget-inputs-wrapper">
<input id="input_178" class="form-hidden form-widget" type="hidden" name="q178_clickTo178" value="" />
<input id="widget_settings_178" class="form-hidden form-widget-settings" type="hidden" value="%5B%7B%22name%22%3A%22height%22%2C%22value%22%3A%22height%22%7D%2C%7B%22name%22%3A%22style%22%2C%22value%22%3A%22solid%22%7D%2C%7B%22name%22%3A%22color%22%2C%22value%22%3A%22%23ffcc00%22%7D%2C%7B%22name%22%3A%22spaceAbove%22%2C%22value%22%3A%22spaceAbove%22%7D%2C%7B%22name%22%3A%22spaceBelow%22%2C%22value%22%3A%22spaceBelow%22%7D%2C%7B%22name%22%3A%22horizontalSpace%22%2C%22value%22%3A%22horizontalSpace%22%7D%5D" data-version="2" />
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</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_textarea" id="id_165">
<label class="form-label form-label-top form-label-auto" id="label_165" for="input_165">
Name of Person Submitting Report
<span class="form-required">
*
</span>
</label>
<div id="cid_165" class="form-input-wide jf-required">
<textarea id="input_165" class="form-textarea validate[required]" name="q165_nameOf" cols="40" rows="4"></textarea>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_131">
<div id="cid_131" class="form-input-wide">
<div style="text-align:center" class="form-buttons-wrapper">
<button id="input_131" type="submit" class="form-submit-button">
SUBMIT
</button>
</div>
</div>
</li>
<li style="display:none">
Should be Empty:
<input type="text" name="website" value="" />
</li>
</ul>
</div>
<input type="hidden" id="simple_spc" name="simple_spc" value="41615880386966" />
<script type="text/javascript">
document.getElementById("si" + "mple" + "_spc").value = "41615880386966-41615880386966";
</script>
<script src="https://d2g9qbzl5h49rh.cloudfront.net/js/widgetResizer.js?REV=3.3.9361" type="text/javascript"></script>
</form>