In my professional opinion, as a licensed Registered Nurse, the situation described on this form is not adequate to meet the needs of the patients assigned to me at this time. I indicate my acceptance of the assignment despite objection. It is not my intention to refuse the assignment. The purpose of this form is to notify facility supervisory staff that I have been given an assignment I believe is potentially unsafe for patients and/or staff. This form will document this situation.
*This assignment is accepted because I have been instructed to do so, despite my objections*
This form information will be automatically sent to committee co-chairs and your organizer.