Section I

 Primary Nurse Charge Nurse Relief Charge

As a patient advocate, in accordance with the California Nursing Practice Act, this is to confirm that I notified you, in my professional
judgment, today’s assignment is unsafe and places my patients at risk. As a result, the facility is responsible for any adverse effects
on patient care. I will, carry out the assignment to the best of my ability.

Section IIa See Title 22 Regulations
 i am objecting to the aforementioned assignment on the grounds that: i was given an assignment where i did not receive or complete orientation to the unit/clinical area( Title 22 sec 70213,70214,70217) validation of current demonstrated competency(Title 22 sec 70213,7021670217)
 I was given an assignment which posted a threat to the health and safety to my patients( examples in Section V )
 Staffing/Skill mix is/was insufficient to : Meet the individual patient care needs/requirements of my patients due to failure to provide additional staff based on acuity ( Title 22 section 70217 ) Perform effective assessments of patients assigned to me( Title 22 section 70215,70217 ) Meet the teaching /discharge needs identified by the patient's condition(Title 22 section 70215) Provide breaks by a direct care RN to prevent fatigue, accident, and/or errors ( Title 22 sec 70217 )
 This unit is staffed with unqualified : Licensed Competent Unlicensed Certified Staff Nursing personnel whose competency was not validated ( Title 22 section 70213, 70016.1 & 70217 )
 Direct patient care duties did not allow time for charge nurse duties-clinical supervision/coordination of care
 Hospital non-compliance with required ratios: 1:1 1:2 1:3 1:4 1:5 1:6 other ( Title 22 section 70217 )
 New patients were transfered/ admitted to unit without adequate staff to stay in compliance with the ratios (Title 22 sec 70717)
 Patient(s) on the unit require a higher level of care then can be provided( Title 22 sec 70217 )
 I was forced to work beyond my scheduled hours of FTE status (Example: Mandatory on Call/Standby)
 Other: Explain in Section V
Section IIb Working Conditions:

 Yes No
 Yes No
 Yes No
Section III Type of Unit:

 Low Medium High Extreme
Section IV Patient Care Staffing Count:

 Yes No
 Yes No
Section V Brief Problem Statement: If more space needed attach additional page.

Section VI Leadership Response

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Choose Han on Duty or Reported to:


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