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The purpose of this survey is to document hours spent on the UW DFM service taking Med Peds Call and Attending.
The first part of the survey asks you to document time in the Hospital while on Med Peds Call. If you did not come in to the hospital, please document "0" (zero) hours.
The second part of the survey asks you to document time while Attending. If you took call while attending during the month, complete both sections.
The third part of the survey asks you to document the time while on BACK UP Attending. If you were not called in, please enter the dates you were scheduled and enter "0" hours.
Surveys must be completed by the last day of each month. If you have questions, please contact Lisa Tiedemann, 608-263-9980, email@example.com. Thank you.
LAST NAME, First Name
For EACH assigned Med Peds Call in a month, please enter the date below and select the number of hours you spent at the hospital. The survey gives you a chance to enter up to three dates/calls.
If you had just one call this month, simply complete the first question and skip the rest. If for some reason you took more than 3 calls in this month, please use the comment section at the end of the survey.
Med Peds Call Date (1):
Total Hours for Med Peds Call 1 Above:
Med Peds Call Date (2):
Total Hours for Med Peds Call 2 Above:
Med Peds Call Date (3):
Total Hours for Med Peds Call 3 Above:
Attending Start Date:
Attending End Date:
Total Hours Attending:
BACK UP Attending Start Date:
BACK UP Attending End Date:
Total Hours BACK UP Attending:
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