Fillable Printable VA Form 0880b

VA Form 0880b

WORKSHEET FOR DETERMINING PERCENTAGES ON MEMORANDUM

SERVICE LEVEL EXPECTATIONS (VA Form 0088a)

NOTE: See VA Handbook 5011, Part II, Chapter 3, for guidance on adjustable work hours for part-time physicians.

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 PHYSICIANDATE (Month/Day/Year)

NAME OF VA FACILITYSERVICE AND SECTION WITHIN VA FACILITY

ESTIMATED EFFORT LEVEL

HOURS PER WEEKHOURS PER YEAR

NAME OF SUPERVISORNAME 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/TIMEFREQUENCY

VA FORM

DEC 2006

0880b

INPATIENT WARD ATTENDING

SERVICE

WEEKS

INPATIENT CONSULT ATTENDING

SERVICE

WEEKS

OPERATING ROOM

SERVICEDAYFREQUENCY

SPECIAL PROCEDURES

SERVICE

DAYFREQUENCY

ADMINISTRATION

POSITIONCOMMENT

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

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 PHYSICIANDATE (Month/Day/Year)

SIGNATURE OF DESIGNATED VA OFFICIALDATE (Month/Day/Year)

CONTINUATION SHEET

VA FORM 0880b, DEC 2006, PAGE 3