DRA Delta Doctors Program - Compliance Closing Survey
Effective: September 4, 2020
Delta Doctors Program
Physician Compliance Closing Survey
Note: Responses to the questions on this survey are strictly confidential. Only designated staff with
the Delta Regional Authority will view the responses to the following questions.
Date: ____________________________
Name: (print or type) __________________________________________________
Years Served: _____________ Employment Start Date:_______________
Address: Home:______________________________ Office:___________________________
Street Street
______________________________ ___________________________
City/State/Zip City/State/Zip
______________________________ ___________________________
Home Phone Work Phone
Physician’s E-mail Address: ______________________________________________________________
Name of Employer: _____________________________________________________________________
Address: ______________________________________________________________________
Street/Location City/State/Zip County
Type of Medical Practice: ________________________________________________________________
(Example: General Practice, Family Medicine, Pediatrics, etc.)
I hereby certify that I, the undersigned, provided direct patient care for the above listed employer for 40
hours per week, or 160 hours per month, at a worksite(s) located within a HPSA or MUA. I further attest
that the information above is truthful and accurate.
I hereby acknowledge that all information and statements contained herein are true and do not misrepresent
facts, per requirements of 18 USC 1001 (Title 18, U.S. Code, Part 1, Chapter 47, Section 1001). I further
acknowledge that I have not evaded or suppressed any information contained in this document or in any of
the supporting materials.
Physician’s Signature: __________________________________________________
Date: __________________________________________________
click to sign
signature
click to edit
![]()
