Report Cross Cover

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Type of cross cover*

During ordinary hours

Outside ordinary hours

Date cross cover occurred or will occur*

End date of cross cover occurance (if overnight)

Start time of cross cover period*

Finish time of cross cover period*

Department or run*

Hospital*

Position of absent RMO*

When was the employer alerted to the vacancy (if known)?*

If unknown, please state 'unknown'

Email address or contact information of responsible manager (if known)?*

If unknown, please state 'unknown'

Was there cover available which was refused or not implemented?*

What was the impact of the vacancy not being covered?*

Any additional comments?

If we need more information, may we contact you about this?*

Identifiable information will not be shared with the employer.

Yes

Name

Mobile

Email (personal)