Share This

Assignment Despite Objection (ADO) Report Form

The purpose of this form is to notify hospital supervisors that you have been given an assignment which you believe is potentially unsafe for patients and/or staff.  This form will document the situation and verify your report.   This form will also provide data that KUNA will tabulate and use to address the problem.        

Do:

  • Verbally notify your unit coordinator/supervisor immediately when you believe you have been given an unsafe assignment
  • Complete this form as soon as possible without interrupting your work or interfering with patient care if your unit coordinator/supervisor does not or cannot make a satisfactory adjustment. (This is usually at the beginning of shift or time of assignment, but may occur at any time).
  • State that you are accepting the assignment and will carry it out to the best of your ability under the circumstances.

Do Not:

  • Use any patient(s) names or identify the patient(s) in any way  
  • Use this form if you have failed to verbally notify your unit coordinator/supervisor.  This form documents you communicated your concerns to a unit coordinator/supervisor
  • Use this form indiscriminately

KUNA will tabulate data collected from these ADO forms and use it to promote changes to improve patient care and staff safety.   

Attach additional pages if needed      

DOWNLOAD THE FORM HERE