CHCA Disclaimer

Connecticut Health Care Associates

NUHHCE, AFSCME, AFL-CIO

261 Center Street Wallingford, CT 06492 Office (203) 265-2297 Fax (203) 284-0624 chcaunion@aol.com

ASSIGNMENT DESPITE OBJECTION LEGAL DISCLAIMER FORM
NAME
FACILITY
Dept/Unit
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,
Assignment Date

- Month - Day Year
Date
Time
Discussed with (Supervisor)
SECTION II: Please check all appropriate statements. I am objecting this assignment on the grounds that:

Staff not trained or experienced in area assigned Staff not given adequate orientation Inadequate staff for acuity (short staffed) The department was staffed with unqualified personnel The 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 option
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:

High Average Low
Influencing Factors. Check those that apply:

Breathing treatments/Vents Patients on isolation precautions multiple lab specimens multiple rapid responses patients on restraints child births with complications patients left on hallways without supervision no support staff unexpected/unscheduled procedures ie. OR/GI/Cardiology Mechanical Issues Other option
Briefly Describe situation.
I hereby disclaim all legal liability connected with the above assignment:
Signature (S )
*Please Print Form Prior to Submission and distribute to delegate and supervisor *
Enter the message as it's shown *
Should be Empty: