• Connecticut Health Care Associates
    NUHHCE, AFSCME, AFL-CIO
    261 Center Street Wallingford, CT 06492 Office (203) 265-2297 Fax (203) 284-0624
    www.chcaunion.org
    info@chcaunion.org
  • ASSIGNMENT DESPITE OBJECTION LEGAL DISCLAIMER FORM
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  • I, the above-named Technical employee, do hereby file this written objection to document the verbal objection to my supervisor regarding my assigned case load,
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    Pick a Date

  • Section III: Complete to the best of your knowledge the patient/work load and acuity at the time of your objection. From your assessment, (if applicable) indicate for each acuity level, the number of patients. If there are acuity factors not listed, please specify what they are. Census and Acuity

  • I hereby disclaim all legal liability connected with the above assignment:
  • *Please Print Form Prior to Submission and distribute to delegate and supervisor *
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  • Should be Empty: