CHCA District 1199 Disclaimer (RN)

ASSIGNMENT DESPITE OBJECTIONLEGAL DISCLAIMER FORM
NAME*
Dept/Unit*
Employer*
Assignment Date*

MonthDayYear
Date
Time*
Discussed with (Supervisor)*
FACILITY
I, the above named Registered Nurse, do hereby file this written objection to document the conversation with my Supervisor objecting to my assignment for the following reasons:
SECTION II: Please check all appropriate statements. I am objecting this assignment on the grounds that:

Staff not trained or experienced in area assignedStaff not given adequate orientation to the unitInadequate staff for acuity (short staffed)The unit was staffed with excessive registryThe unit was staffed with unqualified personnelNew patients were transferred or admitted to the unit without adequate staffThe assignment posed a serious threat to health and safety of staff.The assignment posed a potential threat to health and safety of the patients.Staff involuntarily forced to work beyond scheduled hours.Other
Section III: Complete to the best of your knowledge the patient census and acuity at the time of your objection. From your assessment, indicate for each acuity level, the number of patients on the unit fit into that category. If there are acuity factors not listed, please specify what they are. Census and Acuity
Patient Census: Start
End
Unit Capacity
Number of staff
Admissions
Discharges
Acuity Levels:

HighAverageLow
Factors influencing acuity. Check those that apply:

on respiratorscomplete careon isolation precautionsimmediately post-op (Less than 4 hours)restrainedrequire frequent vital signsreceiving blood products/transfusionsreceiving IV drug/TPN/chemotherapy Infusionson monitors
I hereby disclaim all legal liability connected with the above nursing assignment:
This section can be used to notate any other issues unique to the shift and location
Signature
*Please Print Form Prior to Submission and distribute to delegate and supervisor *
Should be Empty: