Richiesta di attivazione del CdB:
•	Urgente
•	Non urgente

Richiedente ______________________________________________________________________________
U.O. di appartenenza ______________________________________________________________________
Recapito telefonico ________________________________________________________________________

Motivo della consultazione (es. dubbi, pareri discordi sulla modalità di gestione tra l’equipe medico-infermieristica o tra l’equipe medico-infermierista ed i genitori; ecc. max 30 parole.) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Quesito ________________________________________________________________________________________________________________________________________________________________________________

Data ____________________			Firma _____________________________

Far pervenire alla Presidente (Prof.ssa Paola Drigo e-mail : paola.drigo@unipd.it) e alla Segreteria.
Segretaria : Paola Reffo  tel. 049/8213517 – fax 049 8218487 e-mail: direzione.dai@pediatria.unipd.it