ASSIGNMENT DESPITE OBJECTION FORM Sample Clauses

ASSIGNMENT DESPITE OBJECTION FORM. I, , am a Registered Nurse employed at Xxxxxxxx Blood Center hereby object to the assignment made to me by at (Supervisor/Person In Charge) (Time) on despite my objections on the grounds that I was (i.e., not oriented to the (Date) unit, not trained or experienced in area assigned, not given adequate staff for acuity, given an assignment which posed a serious threat to my health or safety, etc.) STAFFING COUNT (on date of objection) RNs: Number of Donors/Patients Scheduled: (on date of objection). Brief statement of problem: This assignment is accepted because I have been instructed to do so, despite my objections. ACTIONS TAKEN BY NURSE: Notified Staffing Coordinator: (Date) (Time) Notified Area Manager: (Date) (Time) Response by Manager:
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ASSIGNMENT DESPITE OBJECTION FORM. I, , a Registered Nurse employed at Xxxxxxxx Blood Center hereby object to the assignment as: made to me by at on despite my (Supervisor/Person In Charge) (Time) (Date) objections on the grounds that I was (i.e., not oriented to the unit, not trained or experienced in area assigned, not given adequate staff for acuity, given an assignment which posed a serious threat to my health or safety, etc.) STAFFING COUNT (on date of objection) PERSONNEL TYPE QUANTITY Phlebotomist Registration Tech/Mobile Unit Assistant Number of Donors/Patients Scheduled: (on date of objection) Brief statement of problem: This assignment is accepted because I have been instructed to do so, despite my objections. ACTIONS TAKEN BY NURSE: Notified Staffing Coordinator: (name) (time) Notified Area Manager: _ (name) (time) Response by Manager RN Signature Date Manager and Title Date Copy #1: to Supervisor Copy #2: to ONA Representative in Center Copy #3: Retained by Nurse Rev: 1/05 FOR THE OHIO NURSES ASSOCIATION/ FOR THE UNIVERSITY OF CINCINNATI AMERICAN FEDERATION OF TEACHERS, AFL-CIO ON BEHALF OF XXXXXXXX BLOOD CENTER Xxxxxxxxxxx Xxxxx Xxxxx Xxxxxxx Xxxxxx Xxxxxxx Xxxxxxx X. Xxxxxxx X.Xxxxxxx Xxxxxxx, Chair, Board of Trustees
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ASSIGNMENT DESPITE OBJECTION FORM. I, , a Registered Nurse employed at Xxxxxxxx Blood Center hereby object to the assignment as: made to me by at on despite my (Supervisor/Person In Charge) (Time) (Date) objections on the grounds that I was (i.e., not oriented to the unit, not trained or experienced in area assigned, not given adequate staff for acuity, given an assignment which posed a serious threat to my health or safety, etc.) STAFFING COUNT (on date of objection) PERSONNEL TYPE QUANTITY Phlebotomist Registration Tech/Mobile Unit Assistant Number of Donors/Patients Scheduled: (on date of objection) Brief statement of problem: This assignment is accepted because I have been instructed to do so, despite my objections. ACTIONS TAKEN BY NURSE: Notified Staffing Coordinator: (name) (time) Notified Area Manager: _ (name) (time) Response by Manager RN Signature Date Manager and Title Date Copy #1: to Supervisor
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