​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.

Staffing Concerns

Check all that apply 

​Workplace Violence

​Assignment Concerns

System failure

Equipment & Supplies

Missed or interrupted breaks

​Earned time denied

Staffing Chart

If the number of support staff was different than the staffing plan please complete the staffing chart below

​Brief Description

​Other Concern

​Actions Taken

​Once you've submitted this form, a copy will be dispatched to the email addresses you've listed above. Additionally, your Local Unit Nurse Representative and the designated ADO recipients as per your Local Unit Contract (e.g., Local Unit Chair, Vice/Co-Chair, Staffing Committee co-chairs, Chief Nurse Officer, Unit Manager) will also receive a copy.

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