Free VA Form VA0880b - Worksheet for Determining Percentages on Memorandum Service Level Expectations - Federal

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

Adobe Forms Designer 7.1

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

Adobe Forms Designer 7.1

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

Adobe Forms Designer 7.1