Texas 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 may jeopardize patient safety or exceed their scope of practice. It requires a written request that includes specific information such as the nurse's name, date and time of the request, location, supervisor's name, and a brief explanation for invoking Safe Harbor. The document emphasizes the importance of collaboration between the nurse and supervisor if the nurse intends to refuse the assignment, and it highlights confidentiality requirements related to these requests.

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Click ‘Get Form’ to open it 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 of 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.

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2008	4.8 Satisfied (202 Votes)

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Texas safe harbor form 2026

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