TENNESSEE MEDICAL FOUNDATION (TMF)
PHYSICIANS HEALTH PROGRAM (PHP)
WORK SITE MONITOR REPORT
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To be submitted to TMF PHP by mail or FAX quarterly (Mar 1, June 1, Sept 1, Dec 1)
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| Participant Name |
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Reporting Quarter |
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| Work Site Monitor |
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Phone |
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To be completed by Work Site Monitor
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How often have you had personal contact in the last three months?
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Please report any observed changes (positive or negative) in the individual's behavior:
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I have observed changes in the individual's attendance |
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If
yes, please explain
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I have observed changes in the individual's personal habits |
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If
yes, please explain
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I have observed changes in the individual's practice performance |
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If
yes, please explain
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I have observed changes in the individual's interpersonal relationships |
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If
yes, please explain
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I have observed changes in the individual's social behavior |
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If
yes, please explain
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I have observed changes related to the individual's use of prescription and/or non-prescription drugs or alcohol? |
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If
yes, please explain
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Did the individual face any significant professional/personal challenges this quarter? |
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If
yes, please explain
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Is the individual's overall performance satisfactory? |
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If
no, please explain
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Do you have any concerns about the individual's workplace performance? |
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If
yes, please explain
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Any additional comments:
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Signature of Work Site Monitor:
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Date: 2/4/2012 |
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Would you like the TMF PHP to contact you?
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| Security Code |
(Type the code you see here into the 'Security Code' box above)
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