36C24618Q9436-008.docx

DOCX document 15 KB Posted Jul 31, 2018

Attached to: Wheelchair Van Transportation Service for the Salisbury VAMC.
Solicitation number: 36C24618Q9436
Issued by: Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 6

About this file

From the source

36C24618Q9436 Verification Sign-in Sign-out Sheet for Transportation Wait Times.docx

On GovTribe

Try for free Login

The file's text, extracted by GovTribe without its formatting.

D.3 VERIFICATION SIGN-IN/SIGN-OUT SHEET FOR TRANSPORTATION WAIT TIMES

VERIFICATION SIGN-IN/SIGN-OUT SHEET FOR TRANSPORTATION WAIT TIMES

Medical Facility & Medical Facility Front Office Staff Information

Name of Contractor's Driver (PRINTED) (First Name, Last Name)

Name of Patient Transported (PRINTED) (First Name, Last Name)

Time Patient Is Signed Into Facility (eg: 7:00 AM)

Time Patient is discharged from Medical Appointment (eg: 7:00 AM)

Time Patient Leaves the Medical Facility (eg. 7:00 AM)

Name of Medical Facility

Printed Name of Medical Facility Front Office Attendant (PRINTED) (First Name, Last Name)

Signature of Medical Facility Front Office Attendant

File details come from the government source that posted it.