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Short Staffing/Assignment Despite Objection

JNESO- DISTRICT COUNCIL 1, IUOE-AFL-CIO

First+ Last Name

*For MANDATORY OVERTIME issues see your steward or check the JNESO website for a N.J. or Pa. Department of Labor Mandatory Overtime Complaint Form and/or Grievance filing

THIS ASSIGNMENT POSES A SERIOUS THREAT TO THE HEALTH AND SAFETY OF STAFF AND PATIENTS

LIABILITY FOR THIS ASSIGNMENT IS PASSED TO ADMINISTRATION

As a patient advocate, in accordance with The Nurse Practice Act, this is to confirm that I notified you that in my professional judgement, this assignment is unsafe and places patients and staff at risk. I indicate my acceptance of this assignment under protest. It is not my intention to refuse to accept the assignment or disobey an order I have been given. I acknowledge my obligations to the patients. However, I hereby give notice to my employer of the above facts and indicate that for reasons listed, full responsibility for the consequences of this assignment rests with the employer. (Copies of this form may be provided to any and all appropriate State and federal agencies).