ADO (Assignment Despite Objection)

‌Use this form to submit a complaint to the Nurse Staffing Committee and Your Local WSNA Nurse Representative.


Staffing Concern

In my professional opinion, this situation poses a risk to the health and safety of patients and/or staff and contributes to errors, omissions, near misses, and/or adverse events.


Workplace Violence

Assignment Concerns

System failure

Equipment & Supplies

Missed or interrupted breaks

Earned time denied

If the number of support staff was different than the staffing plan, please complete the staffing chart below by entering the Planned # of staff & the Actual # on staff.

Brief Description

Other Concern

Actions Taken

If you have additional items or documents you would like to submit please email the attachments to your Local Unit Nurse Representative.

After you submit this form: A copy will be sent to the email addresses you provided above, your Local Unit Nurse Representative, and your designated ADO recipients according to your Local Unit Contract. (Example: Local Unit Chair and Vice/Co-Chair, Staffing Committee co-chairs, Chief Nurse Officer, Unit Manager.)