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Safe harbor form 2026

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The document outlines the procedure for nurses in Texas to invoke 'Safe Harbor' when they believe an assignment is unsafe or outside their scope of practice. It specifies that requests must be made in writing before accepting the assignment and includes required information such as the nurse's name, date, location, supervisor's name, and a brief explanation for the request. The document emphasizes collaboration between nurses and supervisors when refusing assignments and highlights confidentiality requirements.

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Click ‘Get Form’ to open the safe harbor form in the editor.
Begin by entering the Nurse(s) Name(s) invoking Safe Harbor in the designated field. Ensure that all names are clearly written for accurate identification.
Next, input the Date/Time of Request. This is crucial as it establishes the timeline for your request.
Fill in the Location of requested conduct/assignment. Be specific to avoid any confusion regarding where the assignment is taking place.
Provide the Name of person/supervisor making the assignment or requesting conduct. Include their title for clarity.
In the Brief explanation field, articulate why you are invoking Safe Harbor. Referencing rules 217.11 and 217.12 can be beneficial here.
Finally, ensure all signatures are collected: Nurse(s) invoking Safe Harbor and Supervisor/Person Making Assignment must sign before submission.

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