Protest of Assignments 

E-Fillable PDF POA

All the custom POAs so far…

Be sure to fill out your assignment workload to assist in our staffing enforcement arbitration cases!

Moses NW1 POA (Double sided)
CHAM 10 PICU POA (Double sided)
CHAM ED POA (Double sided POA)
Weiler ED POA (Double sided POA)
CHAM 10 PCVCU POA (Double sided)
Moses ED POA (Double sided POA)
Weiler 10 North POA (Double sided)
Moses F6A POA
CHAM 6 POA (Double sided)

CHAM 9 POA (Double sided)
CHAM 8 POA (Double sided)
Modified POA with more additional comment space

What is a POA?

A Protest of Assignment (POA) is a written document notifying the employer that a nursing assignment is unsafe.

As nurses, we would never turn down an assignment. But as patient advocates, it is our duty to do everything in our power to correct unsafe situations.

Filling out a Protest of Assignment can help protect you from malpractice or discipline in the event of an adverse incident.

But the most important reason to fill out a POA is to advocate for a change in conditions so our patients get better care


 During arbitration sessions, we are finding that the POA details are incredibly valuable.

We need your POA comments to paint the picture of what your unit looked like at the time of filing the POA.

Step 1 is filling out the POAs, step 2 is being a witness during arbitration in order to enforce the safe staffing enforcement language we won!

Examples of pre-filled POAs we’ve created for units based on their needs.

The nurses can simply check off the relevant comments instead of having to write out the same things every shift. We’re happy to work with you.


Please review the sample ED POA to learn more about how to fill out the detailed POAs we need for arbitration cases!

SAMPLE ED POA Completed

Never filled out a POA before?

Email completed POA to poa@nysna.org

This looks a little different because it’s the custom CHAM ED POA