The purpose of this form is to notify hospital /clinic supervision that you have been given an assignment which you believe is potentially unsafe for you or your patients. This form will document the situation. UPSC will use it to facilitate resolution of the problem.
A copy will be automatically sent to the supervisor’s email that you input on the form. You will be able to access your copy in “My Profile” in MemberLink https://memberlink.unacuhcp.org/ for your records. UPSC will be able to access your completed form.
You must orally protest your assignment to your supervisor before you complete this form. Please remember to complete name and title of person making assignment.
Examples of Staffing Issues include:
- I was not trained or experienced in area assigned.
- I was not given adequate staff (short staffed).
- The pharmacy was staffed with unqualified personnel.
- I was given an assignment which posed a potential threat to patient health and safety.
- New responsibilities were added without adequate staff.
- I was asked to perform outside my scope of practice.
- I was involuntarily forced to work beyond my scheduled hours.
- I was instructed to take action which may run counter to existing pharmacy regulations.
There is also a Free-Text Box to capture other objections if applicable.