COVID-19 Assignment Despite Objection

Your Name (required)

Your Email (required)

Facility Name
None of theseUniversity HospitalCornerstone Behavioral Health HospitalChrist HospitalCooper University Health CarePalisades Medical CenterVirtua Health AllianceBayonne Medical CenterHarborageEnglewood Hospital and Medical CenterVNA Health Group of New JerseyVisiting Nurses Association of EnglewoodJersey Shore Medical CenterSouthern Ocean Medical CenterWanaque Subacute Care CenterNew Bridge Medical CenterLlanfair HouseHudson Regional HospitalInspira Health - Vineland, Elmer, and BridgetonTemple Episcopal HospitalAmerican Red CrossInspira Health - WoodburyMemorial Hospital of Salem CountyRutgers UniversityRowan UniversityAAC/Sunrise House

Department/Unit Name

Manager's Name

Supervisor/Manager's Email (If you fill out this field, a copy of this notice will be sent to the address)

Date of Incident

Time of Incident

Time Management Notified

I/we hereby object to my/our work assignment on the following grounds: (check all that apply) (required)
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

If other above, please specify:

Comments?

Employees covered by this notice: