Cherokee Nation WW Hastings Hospital - Provider Time Estimate

Fiscal Period: 10/01/2023 to 09/30/2024

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* 1. Enter Personal Information:

First Name:

Last Name:

Specialty:

Date (mm/dd/yyyy):

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* 2. Enter percentage of your time spent in each category below:

Category A includes but is not limited to: Supervision of technicians, nurses, etc. Utilization review, other committee work; Administration or medical director of a department; supervision of interns and residents, teaching, quality control -- but not included in other lines.

Category B includes: Medical/Surgical hands-on patient care services to individual patients, includes and chart review, consultation, etc. that would be specific to an individual patient.

Category C includes but is not limited to: Research, teaching I&R in non-approved programs, work outside the facility such as schools, nursing homes, community, writing for medical journals -- but not included in other lines.

NOTE: Total Should Equal 100; Use whole numbers – no decimals

Administrative (A)

Staff Meetings (A)

CME (A)

Vacation (A)

Sick Leave (A)

Holiday (A)

IP Patient Care (B)

OP Patient Care (B)

Research (C)

Community (C)

Nursing Home (C)

Deployment (C)

Schools (C)

Other (C)

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* 3. If time reported in Question 2 "Other" above, provide a brief description:

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* 4. Enter full name of the person completing this Survey: