Moonlighting Request Form

NOTICE: This Moonlighting Request Form must be submitted as soon as the moonlighting assignment has been made.
Resident Name: *
PGY Level: *
Residency/Fellowship Program: *
VISA Status**: *
Date of Moonlighting shift: *
Hours of Moonlighting shift: *
If other, please use this space to explain why the standard shifts or times do not apply. Please include the location and the start and end times of your moonlighting shift:
Attending Staff Available for Consultation: *
If No, please explain how clinical support for complex cases will be provided:
Regular Rotation Assignment (which rotation are you on when you are requesting to moonlight?): *
For Program Director - I have reviewed this request and agree to allow the above resident to moonlight as described above:
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.