MEMORANDUM for Program Director, NCC Pediatrics Residency

Date______

MEMORANDUM FOR Program Director, NCC Pediatrics Residency

SUBJECT: Extension of Duty Hours and Fatigue Assessment

1. While on ______rotation, I exceeded ACGME duty hour limits on ___/___/______by:

a. Working ____ continuous hours

b. Returning to work after having _____ hours free of duty.

2. I exceeded duty hours because of one of the following unusual circumstances (circle one):

a. Required continuity of care for a severely ill or unstable patient.

b. Academic importance of the events transpiring.

c. Humanistic attention to the needs of a patient or family.

d. Other:______

3. I did/did not receive permission in advance from the attending to exceed duty hours

4. A fatigue assessment was / was not performed by my supervisor, ______.

______

TRAINEE NAME

PGY-1/2/3 PEDIATRICS

______I supervised this trainee and agree with the above. I performed a fatigue assessment and

I deemed this trainee safe to continue providing patient care.

______I performed a fatigue assessment and I deemed it not safe for this trainee to continue

providing patient care so the duty hour extension was not approved and the trainee was

instructed to turn over patient care and rest,

______I spoke to the supervising physician at the outside facility. The supervising faculty

member did / did not perform a fatigue assessment.

______

FACULTY NAME

TITLE OR PROGRAM DIRECTOR

Note: The Program Director must review each submission of additional service, and track both individual trainee and program-wide episodes of additional duty. If a trainee did not meet one of the justifications in items 2 a, b, or c above for exceeding the 24-hour maximum duty period length or did not meet the minimum hours free of duty, the duty hour violation needs to be reported to the DIO and presented at the next monthly GMEC meeting. A description of action(s) taken to prevent future violations, i.e. counseling of trainees/faculty, restructuring of call duties, etc. should be included in the presentation. Circumstances of return-to-hospital activities with fewer than 8 hours away from the hospital by trainees in their final years of education must be monitored by the Program Director.

Quality Assurance Document rule applies under 10USC 1102. Copies of this document thereto, and information there from will not be further released under penalties of law. Unauthorized disclosure carries a statutory penalty of up to $3000 in the case of a first offense, and up to $20,000 in the case of a subsequent offense. . In addition to these statutory penalties, unauthorized disclosure may lead to Adverse Action under UCMJ and/or Adverse Administrative Action, including separation from the Military or Civilian services.