Fillable New York State Nurses Association: COVID-19 Protest of Assignment Form

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New York State Nurses Association: COVID-19 Protest of Assignment Form

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  • 25 check-boxes
  • 21 other fields

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COVID-19 Protest of Assignment Form
To Supplement a Protest of Assignment
Facility code
Facility name ______________________
Date Code of Name of
nursing unit nursing unit __________________________
Name of individual/s filing report:______________________________ Time of Incident: _______________ Location: ________________
Time Management notified _________________________________ Manager's N
ame _____________________________________
What type of nursing unit is this?
What issues are you reporting?
__ Home Care/Public Health
__ Unsafe nurse: patient ratio impedes safe care or
contributes to potential spread of disease
__ Inadequate number of N95 Respirators
__ Not fit tested for respirator, or with proper size.
__ Not given same size/model N95 fitted for originally.
__ Told to reuse N95 respirators when caring for patient on
airborne, droplet and contact precautions
__ Inadequate
number of impenetrable gowns, masks, booties,
face shields/eye protection
__ Screening/triage shortcomings put staff at risk
__ Not adequately trained for using equipment
__ Inadequate number of negative pressure rooms
__ Lack of proper disinfection supplies
__ Strict visitor policy not enforced
__ ICU/MICU/NICU
__
Med/Surg
__
ER
__
Maternity/GYN
__
ICU/MICU/NICU
__
Psychiatry
__ Ambulatory Surgery
__ School
__ Correctional Facility
__ Ambulatory Care Clinic
__ OR/Anesth/Recovery
__ Stepdown/Telemetry
__Nursing Home/Rehab
Other ________________________________________
How many staff exposed as a result?
________________________________
How many patients or visitors
exposed?
______________________________
Other
conditions:_____________________________________________
______________________________________________________
Additional Comments-
Please write on back if more space is needed.
Management Comments and Signature
Number of RNs
signing this form
M M D D Y Y Y Y
Under the laws of NY, as a registered professional nurse, I am responsible and accountable to my clients.
Therefore, this is to confirm that I notified you that, in my professional judgement, today’s assignment is unsafe
COVID-19 Protest of Assignment Form
To Supplement a Protest of Assignment
Facility code
Facility name ______________________
Date Code of Name of
nursing unit nursing unit __________________________
Name of individual/s filing report:______________________________ Time of Incident: _______________ Location: ________________
Time Management notified _________________________________ Manager's N
ame _____________________________________
What type of nursing unit is this?
What issues are you reporting?
__ Home Care/Public Health
__ Unsafe nurse: patient ratio impedes safe care or
contributes to potential spread of disease
__ Inadequate number of N95 Respirators
__ Not fit tested for respirator, or with proper size.
__ Not given same size/model N95 fitted for originally.
__ Told to reuse N95 respirators when caring for patient on
airborne, droplet and contact precautions
__ Inadequate number of impenetrable gowns, masks, booties,
face shields/eye protection
__ Screening/triage shortcomings put staff at risk
__ Not
adequately trained for using equipment
__ Inadequate number of negative pressure rooms
__ Lack of proper disinfection supplies
__ Strict visitor policy not enforced
__ ICU/MICU/NICU
__
Med/Surg
__
ER
__
Maternity/GYN
__
ICU/MICU/NICU
__
Psychiatry
__ Ambulatory Surgery
__ School
__ Correctional Facility
__ Ambulatory Care Clinic
__ OR/Anesth/Recovery
__ Stepdown/Telemetry
__Nursing Home/Rehab
Other ________________________________________
How many staff exposed as a result?
________________________________
How many patients or visitors
exposed?
______________________________
Other
conditions:_____________________________________________
______________________________________________________
Additional Comments-
Please write on back if more space is needed.
Management Comments and Signature
Number of RNs
signing this form
M M D D Y Y Y Y
Under the laws of NY, as a registered professional nurse, I am responsible and accountable to my clients. Therefore, this is to confirm that I notified you that, in my professional
judgement, today’s assignment is unsafe and places my clients at risk. As a result, the Hospital and you share responsibility for any adverse effects on patient care and myself as
an employee working under your direction. I will, under protest, attempt to carry out the assignment to the best of my professional ability.
How to return this POA:
•
Fax to your facility's POA fax line, or to the main NYSNA POA fax lines at 212-785-0429 or
518-782-1286
• Email a scan or
photo to covidpoa@nysna.org
• Text a photo to your NYSNA rep
and places my clients at risk. As a result, the Hospital and you share responsibility for any adverse effects on
patient care and myself as an employee working under your direction. I will, under protest, attempt to carry out
the assignment to the best of my professional ability.
Signature: _____________________________________________________________________________________________
_____________________________________________________________________________________________
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New York State Nurses Association: COVID-19 Protest of Assignment Form

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Completed 29 March 2020

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