MEDICAL DIVISION

SWAPPING FORM

Date and Time: _____________________

Requesting Staff: _____________________ Conforming Staff:___________________
Signature over printed name Signature over printed name

From Date/Shift: _________________________

To Date/Shift: ___________________________

Reason for swapping: _____________________________________________________

__________________________________________________________________________
__________________________________________________________________________

Noted By: Approved by:

_______________________________ EDELISA M. CHAVEZ, MD, FIAMS, DPPS

*Unit head/**ER Senior Resident Chief of Clinics

*Unit affected
**ER affected

FM-MED-01 Date of Effectivity: June 11, 2019