Follow the steps to complete the waiver request form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the facility or agency information. Enter the name of the hospital, the address, and the unit for which the waiver is being requested.
3. Provide details about the individual requesting the waiver. Include the title of the Chief Nursing Officer (CNO) or Chief Nursing Executive (CNE), along with their address, phone number, and email.
4. List the Oregon Administrative Rule(s) you are requesting to be waived by entering the rule number(s) and copying the relevant rule text.
5. Describe the alternative solution you are proposing to address staffing issues.
6. Indicate the specific days and times when the proposed alternative solution will govern unit staffing.
7. Explain the situations during the specified days and times when the alternative solution will not govern unit staffing, considering factors like patient census and acuity.
8. Detail the training and experience of any staff members who will provide direct care in place of nursing staff when the alternative solution is in effect.
9. Specify if Basic Life Support (BLS) or Advanced Cardiovascular Life Support (ACLS) certification is required for this position by checking 'Yes' or 'No.'
10. Write a narrative justification for the request, explaining why the waiver is necessary to ensure the hospital sufficiently meets patient health care needs. Attach additional pages if required.
11. Enter the date on which the Hospital Nurse Staffing Committee was informed of the waiver request.
12. Mention applicable professional standards that support your proposed alternative solutions.
13. Have the CNO/CNE sign the form. Include their printed name and the date of signing.
14. Once all sections are completed, review the form for accuracy before submitting. You can save changes, download, print, or share the form as needed.

Complete your waiver request online today to ensure proper staffing solutions for your facility.