Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in your name in the space provided at the top of the form, marking it clearly as ‘I/WE _______________________________________________________’. This identifies who is submitting the complaint.
3. Indicate your job title(s) in the designated area by writing ‘JOB TITLE(s):________________________’. This helps to establish your professional perspective.
4. Input the name of the facility where you work in the ‘FACILITY: _____________________________________’ section. This is essential for proper routing of the complaint.
5. Specify your shift in the ‘SHIFT: ______________’ field, as this provides context for when the issues occurred.
6. Write the current date in the ‘DATE: __________________’ section to document when this form is completed.
7. Detail the unit or department you work in under ‘UNIT/DEPT: ____________________’, which allows the administration to understand the specific area impacted.
8. Record the time you are filling out the form in the ‘TIME: ___________________’ section. This is important for verifying the timeline of events.
9. Indicate the supervisor you reported to in the space marked ‘SUPERVISOR YOU REPORTED TO: ____________________________________________’. This connects your submission to a supervisory chain.
10. Document the supervisor's response in the ‘SUPERVISOR RESPONSE: ________________________________________________________________________________’ area to provide context for the assignment despite objection.
11. Complete the ‘REASON for ADO’ section by selecting options such as inadequate staffing or untrained personnel. You may also write in other reasons if applicable.
12. In the ‘PATIENT CENSUS’ section, fill in the start and end patient counts along with unit capacity, admissions, and discharges to detail patient load.
13. Under ‘ACUITY LEVELS’, indicate the acuity levels and number of emergency interactions to illustrate the current situation.
14. List the staffing categories including RN, LPN, Clerk/Secretary, Aide, and any other professionals, recording their numbers at the start and end of the shift.
15. Provide a statement of the problem in the designated space, clearly and thoroughly outlining the issues that prompted your assignment despite objection.
16. Document any calls made to relevant departments by filling in the provided information including the date and who you spoke to about the complaint.
17. After completing the form, review all information for accuracy before finalizing it.
18. Finally, save the changes and choose to download, print, or share the form as needed for submission or record-keeping.

Take action on your concerns—complete the Assignment Despite Objection online today.