Clinicians Hotline Data Form | Academy of Aid-in-Dying Medicine

Hotline Data Form

Hotline Clinician

Date call or email received

Name of person calling or emailing

First Last

Requester's Phone #

Requester's Email

Requester's State

Requester's Clinical Role

Question or topic of concern

Response from Hotline clinician

This question was (pick one)

Urgent

Non-urgent

inappropriate (family or patient)

Other (please explain in “Notes” below)

Discussed with or Forwarded to Backup Clinician

Yes

How did requester know about Hotline?

Additional Information or Notes