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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 three 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 jot down the key information necessary to initially invoke safe harbor in writing as required by 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.

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 third form, Safe Harbor Request to Question the Medical Reasonableness of a Physician's Order Form, is for those occasions when the reason for the nurse invoking safe harbor is related to the actions or orders of a physician. In this case, the nurse may not need to use the quick or the comprehensive request forms since it will be an individual physician who will make a determination of medical reasonableness rather than a nursing peer review committee. In other words, to question the medical reasonableness of a physician’s order, a nurse will likely only need to use this third form by itself.

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 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:

  • Rule 217.20 Safe Harbor Peer Review for Nurses and Whistleblower Protections.

The rules relating to incident-based peer review include:

The NPA, Board rules and changes are accessible on the BON web page at: