OPEIU Local 459 - Assignment Despite Objection (ADO)

OPEIU Local 459

Assignment Despite Objection (ADO)
PURPOSE: This form notifies hospital supervision that a Registered Nurse has been given an assignment which the RN, in their professional judgement, believes is unsafe or potentially unsafe. This form documents the situation, may be used by the Union in advocating for safe staffing, and may be shared with appropriate state and federal agencies.

INSTRUCTIONS FOR RN: Please print clearly or use the computer to fill out this form. One or more RNs may complete/sign the form. If you are completing online, you will receive a PDF copy via email. You must forward this PDF to your manager's email address and copy the union at safepatientcare@local459.org. If you are completing a hard copy, send one copy to the Union (fax 517-887-8848, or hand-deliver 838 Louisa St., Suite A, Lansing), one copy to the Supervisor or Manager on duty, and keep one copy for yourself.

Before completing this form you must verbally notify your Supervisor/Manager (not the Contact Nurse) that you protest the assignment because it is unsafe or potentially unsafe. If the Supervisor/Manager does not remedy the situation, complete this form.

In accordance with my obligations as a Professional Registered Nurse and a patient advocate, I am objecting to my work assignment on:
Email*
example@example.com
Unit*
Date*

MonthDayYear
Date
Shift*
I have notified (Name)*
Enter the name
Management Position*
Enter the management position
that in my professional nursing judgment I
Your Name*
Enter your name
am unable to assure the delivery of safe or adequate nursing care.
Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
SECTION 2: I am objecting to this assignment based on the following grounds:

Inadequate nurse-to-patient ratioPatients requiring higher level of care placed inappropriately in unitStaff not trained or experienced in area assigned or equipment providedStaff not given adequate orientation to unitUnqualified personnel or inappropriate personnel mix (RN / NA / UA)Missed breaks/mealsLack of equipment or malfunctioning equipmentNew patients transferred or admitted to the unit without adequate staff. ( RN / NA / UA)Violence in the work placeStaff involuntarily and dangerously forced to work beyond scheduled hours mandatoryOther (please explain):

SECTION 3: Complete to the best of your knowledge:

	RN	NA	UA	Census	Overtime / Mandated Staff
# Start of shift
# End of shift
# Per staffing guidelines for shift

SECTION 4: Complete this section if you think the situation cannot be explained adequately in the previous sections, or if you think additional information is relevant.
As a patient advocate, in my professional judgment, I notified you that this assignment is unsafe and places the patients and/or staff at risk. I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment. However, I hereby give notice to McLaren Greater Lansing of the above facts and indicate that for the reasons listed, full responsibility for any negative consequences of this assignment will rest with McLaren Greater Lansing. The Michigan Public Health Code requires the employer to respond in writing to this notice. See MCL 333.20180(4a. Copies of this form may be provided by Local 459 to any and all appropriate State and Federal agencies.
RN name(s)/title(s)*
Signature(s)*

Clear
Date*

MonthDayYear
Date
Response of Management Representative:*
Name of Management Representative*
Should be Empty: