CHCA District 1199 Disclaimer (Non-RNs)

ASSIGNMENT DESPITE OBJECTIONLEGAL DISCLAIMER FORM
NAME*
FACILITY
FACILITY*
Dept/Unit*
I, the above-named Technical employee, do hereby file this written objection to document theverbal objection to my supervisor regarding my assigned case load,
Assignment Date*

MonthDayYear
Date
Time*
Discussed with *
Supervisor's Name
*

Staff not trained or experienced in area assignedStaff not given adequate orientationInadequate staff for acuity (short staffed)The department was staffed with unqualified personnelThe 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/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
Patients: Start
End
Acuity Levels: *

HighAverageLow
Influencing Factors. Check those that apply:

Breathing treatments/VentsPatients on isolation precautionsmultiple lab specimensmultiple rapid responsespatients on restraintschild births with complicationspatients left on hallways without supervisionno support staffunexpected/unscheduled procedures ie. OR/GI/CardiologyMechanical IssuesOther
Briefly Describe situation.*
Signature
I hereby disclaim all legal liability connected with the above assignment:
Names of other workers on your unit signing onto this disclaimer
Please type one name per line
Signature (S )
Type a question
Type a question
Type a question
*Please Print Form Prior to Submission and distribute to delegate and supervisor *
Should be Empty: