WORKLOAD SCHEDULE LOG

							WORKLOAD SCHEDULE LOG
State Form 53727 (9-08) Indiana State Department of Health-Division of Long Term Care

Surveyor:______________________________________________________ 670 Workload Schedule Facility # ________________________ Complaint # _____________________ Date Arrived: ____________ Pre-survey Prep Hours: ________________ Off-site Prep Hours: _________________ Date 12 am-8 am Off-site 8 am -6 pm Off-site 6 pm – 12 am On-site Travel Hours/Mileage