Act 102 Complaint Details
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Provide the date, hours originally scheduled to work, and the overtime hours worked for each time you had to work mandatory overtime. Include additional sheets if necessary.
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Original Schedule Shift(s):
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Mandatory Overtime:
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1. Did you volunteer to work overtime?
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If Yes, please explain:
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2. Did you agree to be on call?
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If Yes, please explain:
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3. a) At or before the time overtime was requested, were you participating in any procedure?
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3. b) Could your absence have had an adverse effect on the patient?
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If Yes, please explain:
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Did your employer explain the reason for mandatory overtime?
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If Yes, please explain:
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5.To your knowledge, was the overtime required due to any of the following?
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a) Unforseen circumstance?
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b) Vacancies resulting from chronic staff shortages?
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c) A national, state or municipal emergency or other emergency?
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If Yes, please explain:
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6.To your knowledge, did your employer do any of the following?
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a) Ask for volunteers to work overtime?
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b) Contact per diem staff?
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c) Contact a temporary agency?
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d) Provide you with up to one hour to arrange care for children or disabled family members?
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e) Provide you with any documentation concerning efforts to obtain staffing?
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If Yes, please explain:
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If you are aware of any potential witness the Bureau may contact during this investigation, please provide information here:
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