COVERAGE RESPONSIBLITIES

(* = required fields--be sure to fills these out or form will not submit properly)

Resident*: Resident Email*:

 

From
 To
Responsibility Person Covering Email for Coverage *
Pager
Discussed?
Inpatient
Outpatient
Family Therapy
Group Therapy
Day Hospital
Other:        

Notes/Other information:

Other Distribution:

Admissions
Switchboard
Rita Misek
Esther Escotto
Chief Residents
Outpatient Reception
archive on our yahoo group


Other distribution (put in email addresses):

1.
2.
3.

An Email will be sent to each of the persons listed on the coverage list and distribution list.
For Admissions, Switchboard and Outpatient Reception, print this out and fax it.

*(reminder: format for emails: firstname_lastname@brown.edu). All residents are expected to have access to their brown email.
If you need help in forwarding your brown email to a personal email address, information is available on the CIS site, or contact me.

DEADLINE: NO LATER THAN ONE WEEK PRIOR TO SCHEDULED ABSENCE

After you are through filling out form, please submit this by clicking the button below.