Rural Health Care Shift Report Form
Please complete the Rural Health Care Shift Report Form to document your work shift and support continuity of care.
Staff Name
*
First Name
Last Name
Role/Position
*
Please Select
Nurse
Physician
Community Health Worker
Medical Assistant
Other
Date of Shift
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Shift End Time
*
Hour Minutes
AM
PM
AM/PM Option
Facility/Clinic Name or Location
*
Number of Patients Seen During Shift
*
Key Activities Completed
*
Incidents or Issues Encountered
Supplies or Equipment Needed
Handoff Notes for Next Shift
Submit Shift Report
Should be Empty: