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					Revised: August 25, 2005



                                        WEEKLY DUTY HOUR TIME SHEETS
                                         PLASTIC SURGERY RESIDENTS

NEW POLICY: Effective Immediately No Resident will work over 30 Continuous Hours. If resident suspects he/she may be
coming close to 30 continuous hours they must contact Chief Resident to resolve issue. If Chief Resident is unable to do so,
Faculty Member On Call must resolve issue.

PLASTIC SURGERY - RESIDENT
Name _________________________                                             Week of __________________
Please Print Name
PGY 7                                                                      Rotation ______________
                                                                                                         HOURS OFF TILL
                           TIME ARRIVED           TIME LEFT            NIGHT       TOTAL HOURS           START OF WORK
DAY         DATE          HOSPITAL/CLINIC       HOSPITAL/CLINIC        CALL?         WORKED                  NEXT DAY
                                                                                                          ≥ 10 HRS Circle
                                                                                                             Yes or No
Mon                                                                                                     Yes           No
Tue                                                                                                     Yes           No
Wed                                                                                                     Yes           No
Thur                                                                                                    Yes           No
 Fri                                                                                                    Yes           No
Sat                                                                                                     Yes           No
Sun                                                                                                     Yes           No
                                                                                  Total:
DID YOU HAVE ≥24 CONSECUTIVE HOURS OFF THIS TIME PERIOD? PLEASE CIRCLE:                     YES   OR    NO

DID YOU WORK OVER 30 CONTINUOUS HOURS? (Yes or No) Please Circle.             IF SO, EXPLAIN ____________________

__________________________________________________________________________________________________________
                         Reviewed By Program Director /Assoc. Prog. Dir.          _________________________________
                                                                                   Initials        Date

				
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