Instructions to SEIU 521 Represented Employees: When you feel that your working conditions interfere with your ability to provide clients or the public with the expected level of service or safety, or you cannot fully complete your job duties, fill this form out.

Instructions to managers and directors. If an employee gives you this form, please understand that it is legal documentation of current conditions in an operation of Santa Clara County. You should take whatever action you can to remedy the issue and bring it to the attention of the appropriate senior management official.

I am hereby notifying the management of the County of Santa Clara of the fact that I have serious concerns about the conditions in this work area which I have described below.

I will, under protest, attempt to carry out the assignment to the best of my ability.