CWA Local 1168

Protest of Assignment

Digital POA Submission Form

🚧 Digital Protest of Assignment page under construction.

This page is currently being tested. Do not use for live POA submissions yet.

Before You Submit

Use this form to document that you notified your supervisor/manager of an unsafe assignment and are accepting the assignment under protest.

Steps to Follow

  1. Notify the supervisor/manager of the unsafe assignment.
  2. Request assistance or resolution.
  3. Allow the supervisor/manager an opportunity to address the situation.
  4. If unresolved, state that you are accepting the assignment under protest.
  5. Submit this form as soon as reasonably possible.

Important: Do not include patient names, room numbers, medical record numbers, diagnoses, or other patient-identifying information.

Enter the Kaleida email address for the supervisor/manager you notified. This must end in @kaleidahealth.org.
Enter the name of the witness to the conversation with supervision.

Protest of Assignment Statement

Under the laws of this state, as a licensed and certified healthcare professional, I am responsible and accountable to my patients. Therefore, this is to confirm that I notified the supervisor/manager listed above that, in my professional judgment, today's assignment, direction of duties, or practice situation is unsafe and may place patients and/or staff at risk.

I requested assistance or resolution and allowed the supervisor/manager an opportunity to address the situation. If the unsafe situation was not resolved, I accepted the assignment under protest and will attempt to carry out the assignment to the best of my professional ability.

This submission documents the notification to management, the assignment accepted under protest, and whether the supervisor/manager signed or refused to sign.

Sign above
Sign above
Check this only if the supervisor/manager was asked to sign the Protest of Assignment and acknowledged the request but was unable or unwilling to sign.