Medical College of Georgia-Hospital and Clinics
Monthly Record of Hours Worked
Interns, Residents and Fellows
Name:      	
Department:      	
For the Month of:      	
Date	Location:
MCG	Called
In Hours	Number of Calls After Work Hours	Total Time Fielding Calls	Total Disruption Time	
	Time
In	Time
Out					
1	     	     	     	     	     	     	
2	     	     	     	     	     	     	
3	     	     	     	     	     	     	
4	     	     	     	     	     	     	
5	     	     	     	     	     	     	
Total Hrs	     	     	     	     	     	     	
6	     	     	     	     	     	     	
7  	     	     	     	     	     	     	
8  	     	     	     	     	     	     	
9	     	     	     	     	     	     	
10	     	     	     	     	     	     	
11	     	     	     	     	     	     	
12	     	     	     	     	     	     	
Total Hrs	     	     	     	     	     	     	
13	     	     	     	     	     	     	
14  	     	     	     	     	     	     	
15	     	     	     	     	     	     	
16	     	     	     	     	     	     	
17	     	     	     	     	     	     	
18	     	     	     	     	     	     	
19	     	     	     	     	     	     	
Total Hrs	     	     	     	     	     	     	
20	     	     	     	     	     	     	
21	     	     	     	     	     	     	
22	     	     	     	     	     	     	
23	     	     	     	     	     	     	
24	     	     	     	     	     	     	
25	     	     	     	     	     	     	
26	     	     	     	     	     	     	
Total Hrs	     	     	     	     	     	     	
27	     	     	     	     	     	     	
28	     	     	     	     	     	     	
29	     	     	     	     	     	     	
30	     	     	     	     	     	     	
31	     	     	     	     	     	     	
Total Hrs	     	     	     	     	     	     	
Totals	     	     	     	     	     	     	
I certify that this timesheet is properly recorded.
			
Signature		Chairman Signature