For OSUNO Members: This form serves as an ONA/OSUNO Combined Grievance and Assignment Despite Objection submission. It may be used to document an assignment which is potentially unsafe for the patients or staff and serves as a grievance filed over staffing.

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.

For OSUNO Members: This form serves as an ONA/OSUNO Combined Grievance and Assignment Despite Objection submission. It may be used to document an assignment which is potentially unsafe for the patients or staff and serves as a grievance filed over staffing.