File an ADO

Assignment Despite Objection

Report Unsafe Conditions

Documenting an unsafe, inadequate or contract violating situation in 2 easy steps:

Step 1: Verbally protest your assignment to your manager when the situation is inadequate or unsafe.

Step 2: If the situation does not resolve, fill out the Assignment Despite Objection (ADO). A copy of the completed form is sent to you, your labor representative and your manager. Please use a non-work related email address.

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"*" indicates required fields

URL

This field is for validation purposes and should be left unchanged.

Select your employer*

Unit*

Unit where the incident occurred

What is the issue you'd like to report?*

Select all that apply.

Workplace Violence

Understaffing

Unsafe Conditions and Safety Concerns

Inadequate Equipment / Supplies

Missed Breaks & Denied Earned Time

Breastfeeding / Pumping

Workplace Violence

Who was the perpetrator:*

Patient

Visitor

Other

Type of WPV:*

Select all that apply

Verbal threats or abuse

Harassment

Intimidation

Disruptive behavior

Unwanted sexual advances

Verbal or physical conduct of sexual nature

Attempted or actual physical assault with or without a weapon including bodily fluids

Was medical treatment required?*

Yes

Was there destruction of personal property?*

Yes

Describe the destroyed property:*

Was a police report filed?*

Yes

Were you discouraged from filing a police report?*

Yes

I was discouraged because:*

Select all that apply

I did not think reporting would make a difference

I was afraid to report

I was discouraged by my employer

I was told the police wouldn't be willing to make a report

Other (place in comment box at end of form)

Would you like to file a grievance?*

Yes

Article 26
Workplace violence, including actions that disrupt the workplace environment, including physical or aggressive conduct, possession of deadly weapons, or violent behavior(s) that threaten the physical safety of others or the security of property.

Statement of the Grievance*

Grievance Remedy – Make the nurse whole*

Understaffing

Understaffing Issue:*

Select all that apply.

Charge with assignment/unable to perform charge duties

Short staffed for census/ acuity/ complexity

Not trained/ experienced/ oriented to area assigned or floated

All roles of the care team not fully staffed

Floating to multiple units during shift

Forced/ mandatory OT

No clerk/ secretary

Would you like to file a grievance?*

Yes

Side Letter on Staffing, Article 6, Article 8, Article 14
Understaffing, including ratio violations, charge in assignment, preceptor in an inappropriate assignment, management staffing inappropriately for acuity/complexity, or management failing to call for the necessary resources after shifts in staffing or acuity.

Statement of the Grievance*

Grievance Remedy – Make the nurse whole*

Unsafe Conditions and Safety Concerns

Unsafe Condition or Safety Concern:*

Select all that apply.

Unavailable PPE

Denied available PPE

Infectious patient(s) not properly isolated

Failure to test patients meeting signs/ symptoms

Visitor Policy not enforced

Facilities Issues

Would you like to file a grievance?*

Yes

Article 26
Unsafe conditions and workplace safety concerns, including conditions that could cause death or serious illness or injury.

Statement of the Grievance*

Grievance Remedy – Make the nurse whole*

Inadequate Equipment / Supplies

Inadequate Equipment / Supplies:*

Select all that apply.

Unavailable/Missing

Substandard

Needs specialized equipment

Not trained/experienced to use equipment

Medication dispensing machine

Medication bar coder

Computers

Missed Breaks & Denied Earned Time

Missed breaks & Denied Earned Time:*

Select all that apply.

Missed Meal or Rest Breaks

Denied Earned Time: This includes vacation, PTO, Sick, Extended Illness, Education leave

Forced to Work when Sick

Would you like to file a grievance?*

Yes

Article 14
Missed break(s), including: (a) a 15-minute break during the first half of their shift, (b) a 15-minute break during the second half of their shift, and/or (c) a 30-minute meal break per shift.

Statement of the Grievance*

Grievance Remedy – Make the nurse whole*

Breastfeeding / Pumping

Breastfeeding / Pumping:*

Select all that apply.

Delayed break time

Denied break time

Inadequate space provided including: not shielded from view, not free from intrusion of coworkers or public, space was a bathroom, or space not sanitary

Would you like to file a grievance?*

Yes

PUMP for Nursing Mothers Act
The Employer is required to provide nursing employees with a reasonable break time and a private space, other than a bathroom, for expressing breast milk.

Statement of the Grievance*

Grievance Remedy - Cease and desist violation of the Act and make the nurse whole*

Additional Information

Additional Comments: Please provide additional information while maintaining HIPAA standards.

First Name*

Last Name*

Phone Number

Personal Email*

Manager email*

A copy of this form will be sent directly to your manager at the email address provided:

Additional manager email

A copy of this form will be sent directly to your manager at the email address provided:

I hereby object to the assignment as made to me by:*

*List the manager, assistant manager, or house supervisor on duty, NOT the charge person

Date incident occurred*

MM slash DD slash YYYY

9. Shift:*

Select the shift where the majority of your hours were worked

Day shift

Night shift

Role:*

A copy of this form will be sent to the organization CNO.

Incident Information

In my professional opinion, the situation described here is not adequate to meet the needs of the patients assigned to me at this time. Please be aware that while I will do all that I can to ensure safe and proper care for my patients, I fear that my efforts and those of the staff may not be sufficient. Therefore, I am informing you that I am concerned about the possibility of any errors or incidents that may take place as a result of this unsafe condition created by inadequate staffing, systems / equipment failures. The Nurse Practice Act states that nurses shall promote a safe environment for each patient and implement orders in a timely manner. As a patient advocate, in accordance with the Nurse Practice Act, this is to confirm that I notified you that, in my professional judgment, I may be unable to fulfill one or more provision of the Nurse Practice Act because this assignment is unsafe and places the patients or staff at risk. I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment and thus raise questions of meeting my obligations to the patient or of my refusal to obey an order, which were given; however, I hereby give notice to my employer of the facts below and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer. Copies of this form may be provided to any and all appropriate State and Federal agencies.

A copy of this form will be sent to the organization CNO.

Incident Information

A copy of this form will be sent to a member of your organization's management.

Incident Information

In my professional opinion, the situation described here is not adequate to meet the needs of the patients assigned to me at this time. Please be aware that while I will do all that I can to ensure safe and proper care for my patients, I fear that my efforts and those of the staff may not be sufficient. Therefore, I am informing you that I am concerned about the possibility of any errors or incidents that may take place as a result of this unsafe condition created by inadequate staffing, systems / equipment failures. As a surgical technologist, my professional standards emphasize ensuring a sterile and safe surgical environment, advocating for patient safety, and supporting the surgical team. This is to confirm that I notified you that, in my professional judgment, I may be unable to fulfill one or more of these responsibilities because this assignment is unsafe and places patients and staff at risk. I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment and thus raise questions of meeting my obligations to the patient or of my refusal to obey an order, which were given; however, I hereby give notice to my employer of the facts below and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer. Copies of this form may be provided to any and all appropriate State and Federal agencies.

A copy of this form will be sent to the Director of Respiratory Therapy.

Incident Information

In my professional opinion, the situation described here is not adequate to meet the needs of the patients assigned to me at this time. Please be aware that while I will do all that I can to ensure safe and proper care for my patients, I fear that my efforts and those of the staff may not be sufficient. Therefore, I am informing you that I am concerned about the possibility of any errors or incidents that may take place as a result of this unsafe condition created by inadequate staffing, systems / equipment failures. As a respiratory therapist, my scope of practice emphasizes providing a safe environment, advocating for patients, and delivering timely, effective care. This is to confirm that I notified you that, in my professional judgment, I may be unable to fulfill one or more of these professional responsibilities because this assignment is unsafe and places patients and staff at risk. I indicate my acceptance of the assignment under protest. It is not my intention to refuse to accept the assignment and thus raise questions of meeting my obligations to the patient or of my refusal to obey an order, which were given; however, I hereby give notice to my employer of the facts below and indicate that for the reasons listed, full responsibility for the consequences of this assignment must rest with the employer. Copies of this form may be provided to any and all appropriate State and Federal agencies.