Please complete this form.

Housestaff Name:

If you are estimating your hours for a past week, please check here

Service:    AMS/Good Sam Wards Good Sam ICU VA Consult VA Night Float VA ICU VA Wards Other service                          

If you chose "other service" above then fill in the name of the service:

                    Service Name:

PGY       1        2        3        4       other 

Week of:   (dates)

   Were there times you were required to return to work within 10 hours?  Yes   No 

   Were there times you worked more than 30 continuous hours this month?  Yes   No

   Were there issues that you discovered during the 4 weeks of your rotation?   Yes   No 

   It is important for us to monitor fatigue and well-being so we can modify the rotation schedule in the residency program. On average over the last  week, please rate your likelihood to fall asleep in the following situations, click on the below options:

Last question, please fill in the Blank:

I took a nap prior to starting call admissions times (please fill in the number of times) this month

 out of calls (fill in the number of calls)

Total Hours: