APPENDIX A

House Officer Improper Work Duty Assignment Claim

Answer all questions.

1. Today's Date
2. House Officer Name (optional)
3. Program Name
4. House Officer Email
5. House Officer Phone
6. Name of Program Director notified of situation
7. Date that Program Director was notified of the situation
8. Date/Time of Occurrence
9. Unit/Area where Occurrence took place
10. Description of duties/tasks performed
11. Suggested category of personnel that should be performing duties/task