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 firstname.lastname@example.org or fax (201) 262-4335.