Switching 8am to 4pm Form

Form to inform department of switch in 8am to 4pm shift.

DO NOT FILL OUT THIS FORM UNLESS YOU HAVE OBTAINED PERMISSION FROM ALL SENIORS.
This is NOT a request form.
This is just to have a record kept in the office for switches that do not appear on the rota.
This is in case there is medicolegal action in the future and there is need to identify who actually worked on a specific day.

* Indicates required field

Name *

First

Last

Security Code *

Name of person switching with *

First

Last

Has this person agreed to a switch *

Yes No

Date switching from *

Month *

Year *

Where assigned to work *

Consultant covering on date switching from *

Has consultant agreed? *

Yes No

Date switching to *

Month *

Year *

Where switching to *

Consultant covering on date switching to *

Has consultant agreed? *

Yes No

For house officers, please indicate the registrars on duty and state if they have been informed.

Please Fill in Details *

If your arrangement is affecting how you work on a call, please also fill out the appropriate form. Specify any other details of this switch that may be pertinent.

Details *

Submit