Clinicians Hotline Data Form Hotline Data Form Hotline ClinicianCarl DeMarsHunter MarshallJessica KaanLisa StolarczykLonny ShavelsonMindy CooperRobin PlumerThalia DeWolfQuestion received byPhoneTextEmailDate call or email received MM slash DD slash YYYY If by phone or text, the time (approximately) it was received. (Use time zone of receiving clinician.) : Hours Minutes AM PM AM/PM Date of filing this form MM slash DD slash YYYY Name of person calling or emailing First Last Requester's Phone #, if by phoneRequester's Email (if by phone or email) Requester's StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificRequester's Clinical RoleAttending/Prescribing PhysicianConsulting PhysicianAttending/prescribing NP/PAConsulting NP/PANP/PA.(other)Hospice DoctorHospice RN/LVNHospice SWHospice ChaplainHospice VolunteerNon-hospice RNAid-in-Dying VolunteerEnd-of-Life DoulaPatient, family, DPA or caregiver (i.e. non-clinician)Other (fill in below)Requester's Clinical Role — OTHER Topic of call, text or email. Question(s) AskedResponse from Hotline clinicianThis question was (pick one) Urgent, from the bedside or patient’s home Non-urgent/emergent but a relevant question A question that wan’t appropriate/needed A question from a patient or representative Other (please explain in “Notes” below) Discussed with or Forwarded to Backup Clinician Yes No How did requester know about Hotline?Additional Information or Notes