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Clinicians Hotline Data Form
Hotline Data Form
Hotline Clinician
Carl DeMars
Diana Barnard
Hunter Marshall
Jessica Kaan
Lisa Stolarczyk
Lonny Shavelson
Robin Plumer
Thalia DeWolf
Question received by
Phone
Text
Email
Date call or email received
MM slash DD slash YYYY
If by phone or text, the time (approximately) it was received. (Use time zone of receiving clinician.)
Hours
:
Minutes
AM
PM
AM/PM
Date of filing this form
MM slash DD slash YYYY
Name of person calling or emailing
First
Last
Requester's Phone #, if by phone
Requester's Email (if by phone or email)
Requester's State
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American Samoa
Arizona
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District of Columbia
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
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Montana
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New York
North Carolina
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Requester's Clinical Role
Attending/Prescribing Physician
Consulting Physician
Attending/prescribing NP/PA
Consulting NP/PA
NP/PA.(other)
Hospice Doctor
Hospice RN/LVN
Hospice SW
Hospice Chaplain
Hospice Volunteer
Non-hospice RN
Aid-in-Dying Volunteer
End-of-Life Doula
Patient, family, DPA or caregiver (i.e. non-clinician)
Other (fill in below)
Requester's Clinical Role — OTHER
Topic of call, text or email. Question(s) Asked
Response from Hotline clinician
This question was (pick one)
Urgent, from the bedside or patient’s home
Non-urgent/emergent but a relevant question
A question that wan’t appropriate/needed
A question from a patient or representative
Other (please explain in “Notes” below)
Discussed with or Forwarded to Backup Clinician
Yes
No
How did requester know about Hotline?
Additional Information or Notes