Hospital Staffing Reporting

Each hospital licensed by the Connecticut Department of Public Health (DPH) pursuant to chapter 368v shall report, no later than January 1 and July 1 bi-annually, to DPH on a prospective Nurse Staffing Plan that includes all information as required under Public ACT 23-204. Additionally, hospitals and their staffing committee are to develop a hospital objection/refusal form and a hospital staffing complaint form.

Click on the 2025 DPH Annual Hospital Staffing Report

In accordance with Public Act 23-204 hospitals must submit a Hospital Staffing Objection/Refusal Form and a Hospital Staffing Complaint form to DPH for approval.

If a registered nurse who works at the hospital believes that his or her participation in an activity, policy, practice, or task would violate a provision of the staffing plan or policy approved by the hospital’s nurse staffing committee, the nurse may file a complaint with the hospital’s nurse staffing committee on a form developed by the hospital and approved by the DPH.

The table link below provides the DPH approved Hospital Staffing Objection/Refusal Form and Hospital Staffing Complaint Form templates for each hospital licensed by the Department.

 

These forms are to be utilized by hospital personnel (Registered Nurses) to submit concerns to the hospital’s staffing committee; as defined in Public ACT 23-204.

Hospital Staffing Objection/Refusal Form - A registered nurse may object to or refuse to participate in an activity, policy, practice, or task assigned by a hospital if the registered nurse is not competently able based on education, training, or experience to participate in the activity, policy, practice, or task without compromising the safety of a specific patient. Form to be completed and submitted to the hospital for review not later than twelve hours after objecting or refusing to participate in any activity, policy, practice, or task.

Hospital Staffing Complaint Form - If a registered nurse reasonably believes his or her participation in the activity, policy, practice, or task would violate a provision of a nurse staffing plan or policy approved by the hospital’s nurse staffing committee, the nurse may file a complaint with the hospital nursing staffing committee.

Completed forms are to be submitted by the registered nurse directly to the specific hospital and its nurse staffing committee for review. If necessary, please contact the hospital's staffing committee for assistance.

Hospital Name	Location	Approved DPH Form Templates (PDF) - printable
Bridgeport Hospital	267 Grant St, Bridgeport	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Bristol Hospital, Inc.	41 Brewster Rd, Bristol	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Charlotte Hungerford Hospital, The	540 Litchfield St, Torrington	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Connecticut Children's Medical Center	599 Farmington Ave Ste 202, Farmington	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Connecticut Hospice, Inc., The	100 Double Beach Rd, Branford	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Danbury Hospital, The	24 Hospital Ave, Danbury	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Day Kimball Hospital	320 Pomfret St, Putnam	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Gaylord Hospital	50 Gaylord Farm Rd, Wallingford	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Greenwich Hospital	5 Perryridge Rd, Greenwich	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Griffin Hospital	130 Division St, Derby	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Hartford Hospital	80 Seymour St And 200 Retreat Avenue, Hartford	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Hospital For Special Care	2150 Corbin Ave, New Britain	Hospital Staffing Objection/Refusal Form  Hospital Staffing Complaint Form
Hospital Of Central Connecticut, The	100 Grand St, New Britain	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
John Dempsey Hospital Of The University Of Connecticut Health Center	263 Farmington Ave, Farmington	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Johnson Memorial Hospital	201 Chestnut Hill Rd, Stafford Springs	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Lawrence + Memorial Hospital	365 Montauk Ave, New London	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Manchester Memorial Hospital	71 Haynes St, Manchester	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Middlesex Hospital	28 Crescent St, Middletown	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Midstate Medical Center	435 Lewis Ave, Meriden	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Mount Sinai Rehabilitation Hospital, Inc.	490 Blue Hills Ave, Hartford	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Norwalk Hospital	24 Stevens Street, Norwalk	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Rockville General Hospital	31 Union St, Vernon Rockville	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Saint Francis Hospital And Medical Center	114 Woodland Street & 500 Blue Hills Avenue, Hartford	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Saint Mary's Hospital, Inc.	56 Franklin St, Waterbury	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Sharon Hospital	50 Hospital Hill Rd, Sharon	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
St. Vincent's Medical Center	2800 Main St, Bridgeport	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Stamford Hospital, The	Po Box 9317, Stamford	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Waterbury Hospital, The	64 Robbins St, Waterbury	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
William W. Backus Hospital, The	326 Washington St, Norwich	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Windham Community Memorial Hospital, Inc.	112 Mansfield Ave, Willimantic	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form
Yale New Haven Hospital, Inc.	20 York St, New Haven	Hospital Staffing Objection/Refusal Form Hospital Staffing Complaint Form