GMHA Nursing Forms

The following GMHA Nursing Forms have been officially approved for use.  These forms may not be duplicated, manipulated or stored elsewhere. Should the equivalent electronic form(s) become unavailable for use in the hospital’s Electronic Health Record, Nurses shall utilize the forms provided here.

Nursing Departments are required to:

1. Print the required amount of the form(s) necessary for documenting
2. Appropriately complete the form(s)
3. Ensure to Sign, date and time as indicated on the form(s)
4. File the form(s) in the medical chart once done

Any questions regarding the use of these forms shall be directed to your Unit Supervisor or Unit iMed Team Representative.

             Vaccine Information Statement: Inactivated Influenza Vaccine

             Vaccine Information Sheet – Pneumococcal Conjugate Vaccine

             Vaccine Information Sheet – Pneumococcal Polysaccharide Vaccine

 Nursery-NICU Boarder Consent – Form-002

Academic Education for Long Term Pediatric Patients – Form-003

Consent for Chemotherapy

Chemotherapy Waste Disposal Record Form

HRFE Medications IV Assessment Form

Ticket to Ride – Ticket to Return Form

Interfacility Transfer Note

EVOC Transport Run Sheet Form

Behavioral Activity Assessment – Form-16-004

Suicide Precaution Orders – Form-49045

Suicide Discharge Instructions – Form-16-027

Suicide Environmental Assessment – Form-16-028

Suicide Screening Tool – Form-16-029

Boarder Patient RN-LPN Shift Assessment – Form-16-088 

Boarder Patient Medical RN-LPN Adult Shift Assessment – Form-16-089

Boarder Patient PEDS RN-LPN Shift Assessement – Form-16-090 

Patient Observation Flowsheet – Form-16-091

Off-Island Transfer Forms

Patient Escort Clinical Competency Checklist

Physician’s Certificate of Transfer/Refusal to Consent to Transfer

Agreement for Reimbursement of Patient Transfer Services Form

GIAA Release of Liability

Off-Island Transfer Schedule

Patient Transfer Record

Patient Transfer Expernse Report Form

Post Transfer Checklist

Request for Per Diem