Assignment Objection

Assignment Objection - UPSC

Instructions

The purpose of this form is to notify hospital /clinic supervision that you have been given an assignment which you believe is potentially unsafe for you or your patients. This form will document the situation. UNAC/UHCP will use it to facilitate resolution of the problem.

A copy will be automatically sent to the supervisor's email that you input on the form. You will be able to access your copy in "My Profile" in MemberLink https://memberlink.unacuhcp.org/ for your records. UNAC/UHCP will be able to access your completed form.

You must orally protest or protest via written communication your assignment to your supervisor before you complete this form. Please remember to complete name and title of person making assignment.

Contact Information

Employee Name*

Personal Email*

Personal Phone Number*

Work Location*

Unit*

Sub-Unit

Shift Time*

Protest My Role As (Check all appropriate boxes)

Staff Pharmacist

Pharmacist-In-Charge

Preceptor/Trainer

Lead Pharmacist

Other

In the Setting

Home Infusion

CRP/MOPC

Inpatient

Outpatient

AmCare

Made To Me By

Name/Title of Supervisor*

Date/Time of Objection*

Objection Reasons (Check all appropriate boxes)

I was not trained or experienced in area assigned.

I was not given adequate staff (short staffed).

The pharmacy was staffed with unqualified personnel.

I was given an assignment which posed a potential threat to patient health and safety.

New responsibilities were added without adequate staff.

I was asked to perform outside my scope of practice.

I was involuntarily forced to work beyond my scheduled hours.

I was instructed to take action which may run counter to existing pharmacy regulations

Other reason for objection: (if applicable)

Start Of Shift

Workload

Description of Workload

Number of RPh

Number of Technicians

Number of Assistants

Number of Other (Students/Interns/Residents)

End Of Shift

Workload

Description of Workload

Number of RPh

Number of Technicians

Number of Assistants

Number of Other (Students/Interns/Residents)

Notified Supervisor

Reason why your supervisor was not notified*

Supervisor Name/Title

Notified Supervisor Date/Time

Supervisor's Email*

Supervisor Response

Additional

Comments

Clear

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