COVID-19 Assignment Despite Objection - Health Professionals & Allied Employees

COVID-19 Assignment Despite Objection

Instructions:

Inform your supervisor about your objection to your assignment at the time you believe it is unsafe. If your supervisor does not adjust your assignment satisfactorily, complete this form as soon possible without interrupting patient care or your work. Make sure you have your supervisor’s email so they will receive a copy. For paper forms, keep a copy for your records and give a copy to your supervisor or manager. Email or fax a copy to HPAE at office@hpae.org or fax (201) 262-4335.

Click here for a printable version of the form.



Inadequate staffingNot adequately trained for assignment, floated or reassigned without proper trainingLack of N95 respiratorsTold to reuse respirator; length of time/days reused: ___Not fit-tested for respiratorNot given same size/model respirator originally fit-testedLack of face shield/eye protectionLack of masks, impenetrable gowns, gloves, bootiesCOVID-19 patient not wearing facemaskForced/mandatory overtimeTold to work while COVID positive/displaying symptomsLack of PAPRsLack of ventilatorsLack of disinfectant suppliesInadequate number of negative pressure roomsCOVID-19 patient(s) not properly isolatedNot using dedicated staff for COVID-19 patientsVisitor restriction policy not enforcedGiven assignment when immunocompromised, pregnant, breastfeeding or 65 and olderTold not to use self-provided PPEFailure to test patients displaying COVID symptomsOther