​STAFFING COMPLAINT FORM

ADO (Assignment Despite Objection)

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

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​​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.

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​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.)