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Objection To Assignment Form

As healthcare workers, there are times when we feel that management is asking us to do work that is unsafe for ourselves or our patients. That’s why we want to make sure everyone understands their right to object to an assignment.

Please Note: By filling out an objection-to-assignment form, you are not refusing to perform the work assignment. But you are doing so under protest.

Filling out an objection-to-assignment form makes management aware of the unsafe conditions so they have the opportunity to remedy it. If management doesn’t act, filling out the form serves to document the unsafe working conditions, and put the legal liability on management should something bad occur.

Online Form

Fill out an objection-to-assignment form

Instructions

  1. Choose your facility.
  2. Fill out the form with your name, contact information, unit where the unsafe assignment occurred, some details about the assignment and the name of the supervisor that you made aware of the situation.
  3. Click “submit” to email a copy to yourself and NUHW.
  4. You will then be asked if you want to print or email a copy of the completed objection-to-assignment form to your supervisor. If you chose “email to supervisor,” enter your supervisor’s email and it will be sent to them. If you print the completed form, you can also hand deliver a hard copy to your supervisor.
  5. If you are unable to print or email the completed form, let your organizer know that it has been completed, and they can forward it to the appropriate supervisor.
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