O MEDICAL SERVICES UTSIDE PRACTICE AND OTHER BUSINESS ACTIVITIES

CONTRACTOR SAFETY PROGRAM MANUAL FOR STOWERS INSTITUTE FOR MEDICAL
DATE ATTN MEDICAL DIRECTOR PHYSICIAN NAME MD INSTITUTIONINSURANCE COMPANY
RESOLUTION  (A11) PAGE 3 OF 4 AMERICAN MEDICAL

RESOLUTION 904  (I06) PAGE 2 AMERICAN MEDICAL ASSOCIATION
COLLEGE OF HEALTH RELATED PROFESSIONS CONTINUING EDUCATION MEDICAL
CONDITION SPECIFIC MEDICAL ADVICE FORM FOR A STUDENT

Outside Practice and other Business Activities template










O

Medical Services

UTSIDE PRACTICE AND OTHER BUSINESS ACTIVITIES

In Schedule 1 of the Contract, it is a requirement for Senior Medical Officers to notify Metro North Hospital and Health Service of all other engagements, whether as an employee, contractor or business owner. You must also provide updated information if your situation changes. Please provide these details in the form below, using as many rows as you need if you have more than one other engagement. Please return this form by email to [email protected], or call 3328 9122 to clarify any aspect of the information required.

NAME: ____________________________ FACILITY: ____________________________ SPECIALITY: ____________________________ DATE: ____________



1. Nature of engagement:

Location:

Working times and duration of work (specify days/hours):

On call commitments:

Other comments/notes:






2. Nature of engagement:

Location:

Working times and duration of work (specify days/hours):

On call commitments:

Other comments/notes:







3. Nature of engagement:

Location:

Working times and duration of work (specify days/hours):

On call commitments:

Other comments/notes:






4. Nature of engagement:

Location:

Working times and duration of work (specify days/hours):

On call commitments:

Other comments/notes:






5. Nature of engagement:

Location:

Working times and duration of work (specify days/hours):

On call commitments:

Other comments/notes:














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HOSPITAL MEDICAL STAFF POLICY SUBJECT DISRUPTIVE BEHAVIOR
HSR PLAZA II 4100 MEDICAL PARKWAY CARROLLTON TEXAS
MEDICAL PERSONNEL DEPT 8 BEECH HILL ROAD


Tags: activities in, activities, services, medical, utside, practice, business, other