Assignment Despite Objection

Assignment Despite Objection
IFull Name*, hereby object to the assignment as Supervisor* made to me by Person in Charge* at Time* on Date* .
In my professional opinion, this assignment is not safe for the following reasons:*

Inadequate staffingNot trained in area assignedNecessary equipment is not availableThis assignment posed serious threat to my health and safetyInsufficient support staffNot trained for assigned positionNot trained to use equipmentOther
Brief statement of problem(s), including any pertinent information:*
NOTE: Complete this form and have it signed by your immediate Supervisor. When you submit this form a copy will be emailed to the email address you provide below. Please print the completed form and get it signed by your immediate Supervisor. Keep one copy, give one to your Supervisor, and send one to VSEA@VSEA.org. Thank you!
Email*
example@example.com
Name Signature Date
Action Taken:
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