NOTE: See VA Handbook 5011, Part II, Chapter 3, for guidance on adjustable work hours for part-time physicians.
WORKSHEET FOR DETERMINING PERCENTAGES ON MEMORANDUM SERVICE LEVEL EXPECTATIONS (VA Form 0088a)
PRIVACY ACT STATEMENT: The Department of Veterans Affairs (VA) is asking you to provide the information on this form under the authority of Section 7405(a)(1)(a) of Title 38, United States Code in order for VA to determine the expected level of commitment and estimate the amount of time a part-time physician is expected to dedicate to patient care, administrative, research, and educational activities. The information you provide will become part of the "General Personnel Records (Title 38)-VA" (76VA05) Privacy Act system of records. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law enforcement; litigation in which the United States is a party or has an interest; Federal or State licensing boards; and personnel administration. Providing this information to VA is voluntary. However, if you do not provide the information, VA will be unable to employ you as part-time physicians placed on adjustable work hours must complete and sign a Memorandum of Service Level Expectations.
NAME OF PHYSICIAN DATE (Month/Day/Year)
NAME OF VA FACILITY
SERVICE AND SECTION WITHIN VA FACILITY
ESTIMATED EFFORT LEVEL HOURS PER WEEK HOURS PER YEAR
NAME OF SUPERVISOR
NAME OF TIMEKEEPER
EFFORT DISTRIBUTION
ACTIVITY HOURS PER WEEK (Give range for intermitent activities) OVERALL PERCENT OF EFFORT
1. Clinic 2. Inpatient ward attending 3. Inpatient consult attending 4. Operating room 5. Special procedures 6. Administration 7. Teaching 8. Research 9. Total
SERVICE ASSIGNMENTS
CLINIC NAME OF CLINIC DAY/TIME FREQUENCY
VA Form DEC 2006
0880b
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INPATIENT WARD ATTENDING SERVICE WEEKS
INPATIENT CONSULT ATTENDING SERVICE WEEKS
OPERATING ROOM SERVICE DAY FREQUENCY
SPECIAL PROCEDURES SERVICE DAY FREQUENCY
ADMINISTRATION POSITION COMMENT
COMMITTEES (Include joint VA/affiliate committees) COMMITTEE POSITION
DIDACTIC TEACHING ACTIVITIES (Include preparation time, curriculum development) ACTIVITY COMMENT
VA FORM 0880b, DEC 2006, PAGE 2
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RESEARCH (List or append approved projects, indicating location of research and sponsorship (if any). Continue on the blank page 3 provided (if needed)) EXPECTATIONS RELATED TO VA APPOINTMENT
1. The service chief/manager or other appropriate supervisory official must approve changes in clinical assignments, and all clinical assignments must be covered. 2. You must be engaged in approved VA work during your scheduled work hours. 3. All leave (annual leave, authorized absence, etc.) must be recorded. Leave must be requested and reported in advance. 4. Whenever possible, you are to submit requests for adjustments to your biweekly work requirements in advance.
SIGNATURE OF PHYSICIAN DATE (Month/Day/Year)
SIGNATURE OF DESIGNATED VA OFFICIAL
DATE (Month/Day/Year)
CONTINUATION SHEET
VA FORM 0880b, DEC 2006, PAGE 3
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