WORKSHEET FOR DETERMINING PERCENTAGES ON MEMORANDUM
SERVICE LEVEL EXPECTATIONS
(VA Form 0088a)
NOTE: See VA Handbook 5011, Part II, Chapter 3, for guidance on adjustable work hours for part-time physicians.
PRIVACY ACT STATEMENT: The Department of Veterans Affairs (VA) is asking you to provide the information on this form under
the authority of Section 7405(a)(1)(a) of Title 38, United States Code in order for VA to determine the expected level of commitment and
estimate the amount of time a part-time physician is expected to dedicate to patient care, administrative, research, and educational
activities. The information you provide will become part of the "General Personnel Records (Title 38)-VA" (76VA05) Privacy Act
system of records. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use"
disclosure of the information for: civil or criminal law enforcement; litigation in which the United States is a party or has an interest;
Federal or State licensing boards; and personnel administration. Providing this information to VA is voluntary. However, if you do not
provide the information, VA will be unable to employ you as part-time physicians placed on adjustable work hours must complete and
sign a Memorandum of Service Level Expectations.
NAME OF PHYSICIAN
DATE (Month/Day/Year)
NAME OF VA FACILITY
SERVICE AND SECTION WITHIN VA FACILITY
ESTIMATED EFFORT LEVEL
NAME OF SUPERVISOR
NAME OF TIMEKEEPER
HOURS PER WEEK
HOURS PER YEAR
EFFORT DISTRIBUTION
HOURS PER WEEK
ACTIVITY
OVERALL PERCENT OF EFFORT
(Give range for intermitent activities)
1. Clinic
2. Inpatient ward attending
3. Inpatient consult attending
4. Operating room
5. Special procedures
6. Administration
7. Teaching
8. Research
9. Total
SERVICE ASSIGNMENTS
CLINIC
NAME OF CLINIC
DAY/TIME
FREQUENCY
0880b
VA Form
DEC 2006