Florida Nurses Association  OPEIU Local 713

SAFE STAFFING FORM

Assignment Being Protested



   EVERY


   PATIENT


   COUNTS!



 COMMON OBJECTIONS​

​

List the number(s) of the objection statement that best coincides with you objection protest/complaint.  Place that number(s) in the appropriate box on the Safe Staffing Form on the right (i..e. see Form, the 4th text box).

  1. I was not trained or experienced in area assigned.
  2. I was not given adequate orientation to the unit.
  3. I was not given adequate staff for acuity (short staffed).
  4. The unit was staffed with unqualified personnel.
  5. New patients were transferred or admitted to the unit without adequate staff.
  6. I was given an assignment which posed a serious threat to my health and safety.
  7. I was given an assignment which posed a potential threat to the health and safety of my patients.
  8. I was involuntarily forced to work beyond my scheduled hours.
  9. Lack of relief for breaks/lunch.
  10. Lack of auxiliary help such as housekeeping, pharmacy, clerical, CNA, Tech, Sitter, messengers, other medical staff, or had lack of maintenance/equpment.
  11. I received an employee injury.
  12. I became a victim of Workplace Violence.
  13. My patient was injured.
  14. Other (write in your objection)


OBJECTION STATEMENT

As a registered professional nurse, I am responsible and accountable to my patients/clients.  Therefore, this is to confirm that I notified my supervisor that, in my professional judgement, today's assignment is unsafe and places my patients/clients at risk for the reasons stated above.  As a result, the Hospital/Agency is fully responsible for any adverse effects on patient/client care.


However, I will, under protest, attempt to carry out the assignment to the best of my professional ability.