Moonlighting Request Form :: Nationwide Children's Hospital
Resident/Fellow (Trainee) Moonlighting Request Form

NOTICE:
This Moonlighting Request Form must be submitted as soon as the
moonlighting assignment has been made.
Trainee Name: *
PGY Level: *
Residency/Fellowship Program: *
Current Rotation: *
PREREQUISITES
The Trainee has a current, unrestricted Ohio Medical License: *
Trainee is NOT permitted to moonlight on an Ohio Training Certificate.
The Trainee is here on a J-1 Visa: *
Federal regulations prohibit trainees on J-1 Visas from working or receiving compensation for activities outside the approved trainging program, including moonlighting.
The Trainee is in good standing, including no violations of duty hours in the past 3 months and all orders are signed: *
Trainees who have not fullfilled the obligations of the GME program are not permitted to moonlight.
The Trainee seeks to moonlight as an independent practitioner: *
If you answered 'Yes' to the previous question, has the Trainee been credentialed by the Medical Staff?:
If no, the Trainee may only moonlight as a resident.
MED PED RESIDENTS ONLY
The trainee has met acceptable levels in Medical Knowledge per Med-Peds Residency Guidelines and is actively participating in Board Review activities if assigned:
The trainee is on track to meet the required 200 hours of conference time by the end of the academic year:
If you answered no to either of the 2 questions above, contact Dr. Holliday before signing up for any moonlighting.
REQUEST
Approval of this moonlighting request authorizes the trainee to participate based upon current conditions. If circumstances change (e.g., need to work additional regular duty hours), moonlighting approval is rescinded. The trainee must assure that all terms and conditions of moonlighting are met before agreeing to any assignment.
Date of Moonlighting Shift: *
Hours of Moonlighting Shift: *
Location of Moonlighting Shift: *
By clicking "Submit" below, you are electronically signing that you agree to the below statement.
I understand that moonlighting is in addition to the regular duties of my residency. I believe this moonlighting activity will not interfere with my ongoing patient care and educational responsibilities. I understand that future requests to moonlight are contingent upon my ability to successfully complete all of my regularly assigned resident duties. I further attest that I have met all of the conditions outlined in the GME policy on Moonlighting, including visa status, available on the Children’s Intranet (only accessible from within Nationwide Children's Hospital): http://www.intranet/home/Education/GME/moonlighting.pdf

Reminders:

Please remember to fill out Moonlighting forms for all shifts for record keeping purposes. However, please remember if you are Moonlighting in the ED you need to make sure you are turning in the additional form required by the ED.

Visa Status for moonlighting

**For the protection of the resident, the Program Director must assure that an international resident does not violate his/her legal status by moonlighting.

Federal regulations stipulate that residents on J-1 visas may not work or receive compensation for activities outside the approved training program, AS A RESULT, J-1 VISA HOLDERS MAY NOT MOONLIGHT UNDER ANY CIRCUMSTANCES. 

Federal regulations stipulate that residents on H1-B visa must apply and be approved for additional H1-B sponsorship in order to be employed outside their approved program.  Program Directors must contact the GME Office (722 4905) to confirm that a resident on a H1-B visa is legally permitted to moonlight.

Nationwide Children's Hospital
700 Children's Drive Columbus, Ohio 43205 614.722.2000