Safe Harbor Forms - Nursing Peer Review
The Texas Board of Nursing (BON or Board) has safe harbor nursing peer review forms available to make the process faster and easier for a nurse who believes he/she is being asked to accept an unsafe assignment, engage in conduct beyond his/her scope of practice, or engage in unprofessional or illegal conduct. The Board provides the following forms which may be used as part of the safe harbor nursing peer review process. Safe harbor is a process between the nurse and the employer; please do not send these forms to the BON.
The BON Safe Harbor Quick Request Form is an abbreviated form to allow a nurse to quickly write down the key information necessary to initially invoke safe harbor in writing as required by Board Rule 217.20(d)(3) at the time the nurse is asked to accept what he/she believes to be an unsafe assignment or engage in conduct he/she believes could result in a violation of the Nursing Practice Act (NPA) or Board rules. Use of the BON's form is not required but is provided to make invoking safe harbor an easier process for the nurse.
**If a nurse is unable to complete a Safe Harbor Quick Request or other written form meeting the requirements for a Safe Harbor Quick Request due to immediate patient care needs, the nurse may orally invoke safe harbor by notifying the nurse's supervisor of the request. After receiving oral notification of a request, the nurse's supervisor must record in writing the requirements of a Safe Harbor Quick Request, described in Board Rule 217.20(d)(3), which must be signed and attested to by the requesting nurse and the nurse's supervisor who prepared the written record. The BON Safe Harbor Quick Request Form can be used to meet these requirements as well, however, use of the BON's form is not required but is provided to make invoking safe harbor an easier process.
The BON Comprehensive Written Request for Safe Harbor Nursing Peer Review Form is a sample form that may be used to document the more in-depth information that the nurse must put in writing before leaving the work setting at the end of the work period. The nurse may supply supporting documents at a later time; however, the comprehensive details of the event(s) surrounding the request for safe harbor must be recorded prior to the nurse leaving the premises, as outlined in Board Rule 217.20(d)(4). The comprehensive form also includes a fill-in-the-blank format that the nursing peer review committee and chief nursing officer or nurse administrator can utilize to document the safe harbor nursing peer review process. Again, use of the Board's form is not mandatory but is offered as a guide to assist the nurse with meeting the requirements of a comprehensive written request for safe harbor nursing peer review. An entity required to have a nursing peer review plan must have policies and procedures that encompass, at a minimum, the requirements of the applicable statutes and rules related to nursing peer review from the BON. In other words, it is not sufficient to use the Board's forms for safe harbor in place of official policies and procedures on nursing peer review.
The BON Safe Harbor Resources for Facilities document was designed by Board staff to help facilities document their safe harbor nursing peer review process. This document is a guide, and the use of this document is not required by a BON law or rule during the safe harbor nursing peer review process within a facility. The facility should have policies and procedures concerning safe harbor and may require use of specific documentation forms.
A facility or other entity establishing a nursing peer review plan may create its own forms and procedures that comply with the nursing peer review statutes (Texas Occupations Code Chapter 303, Nursing Peer Review) and Board rule (Board Rule 217.20, Safe Harbor Nursing Peer Review and Whistleblower Protections).
You may wish to review answers to Frequently Asked Questions concerning Nursing Peer Review in addition to the resources and forms hyperlinked above.
Review of the entire Board rule concerning safe harbor is also recommended:
The rules relating to incident-based nursing peer review include:
The NPA, Board rules, and rule changes are accessible on the BON web page at: