AFGE Local 903
Assignment Despite Objection Form
The purpose of this form is to notify hospital Supervision that you have been given an assignment which you believe is potentially unsafe for the patients and/or staff. This form will document the situation. The Union may use it to address the problem. 
                                 (Please print clearly or use the computer to fill out this form.)
One or more Registered Nurses (RN's) may complete/sign the form.  Send one copy of this form to the Union via inter office mail, email it, fax it: 573-814-6606 or drop it by the office, Room 542.
     One copy provide to the Supervisor or Manager on duty and keep a copy for yourself. 

                                                                           SECTION A: 

Before accepting the assignment and completing this form, you must give your Supervisor/Manager (not the Charge Nurse) notice of your objection to the assignment in writing.

Please put the complete name and title of the person(s) making the assignment and receiving the objection. Submit a copy of  the completed form to the next level of administration as well.

In accordance with my obligations as a Registered Professional Nurse as well as a Patient Advocate, I am objecting to my current work assignment on unit: *
that in my professional nursing judgment, I am unable to assure the delivery of safe and/or adequate nursing care as a:
                                                                        SECTION B: 
                                   I am objecting to this assignment on the grounds that:       
                                             (Please Check all appropriate statements:) 
                                                                 SECTION C: 
Complete to the best of your knowledge the patient census at the time of your problem.  
From your assessment, indicate for each acuity level, the number of patients on the unit that fit into that category.    
                                     (If there are acuity factors not listed, please specify:)
Patient Census at Start of Shift:
Patient Census at End of Shift:
Number of Discharges:
Number of Admissions:
Unit Capacity:
Number of Transfers:
                                                                Factors Influencing Acuity:   
                     (Check ALL that apply and indicate the numbers needed for clairification)
0/225 words
0/225 characters
     One copy provide to the Supervisor or Manager on duty and keep a copy for yourself. 
                                                                               SECTION E:
I indicate my acceptance of the assignment despite objection. I will despite objection attempt to carry out the assignment to the best of my professional ability. It is not my intention to refuse to accept the assignment and thus raise the questions of meeting my obligations to the patient or of my refusal to obey an order, if such was given.
However, I hereby give notice to my employer of the above facts and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer.
                         Copies of this form may be provided to any and all appropriate state and federal agencies.
Please Sign: *
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