Resident/Fellow (Trainee) Moonlighting Request FormNOTICE: This Moonlighting Request Form must be submitted as soon as the moonlighting assignment has been made. Trainee First Name:

Trainee Last Name:

Email Address

PGY Level:

PGY1 PGY2 PGY3 PGY4

Residency/Fellowship Program:

Current Rotation:

PREREQUISITESThe Trainee has a current, unrestricted Ohio Medical License:

No

Yes

Trainee is NOT permitted to moonlight on an Ohio Training Certificate.The Trainee is here on a J-1 Visa:

No

Yes

Federal regulations prohibit trainees on J-1 Visas from working or receiving compensation for activities outside the approved training 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:

No

Yes

Trainees who have not fulfilled the obligations of the GME program are not permitted to moonlight.The Trainee seeks to moonlight as an independent practitioner:

No

Yes

If you answered ‘Yes’ to the previous question, has the Trainee been credentialed by the Medical Staff?:

No

Yes

MED PED RESIDENTS ONLYThe trainee has met acceptable levels in Medical Knowledge per Med-Peds Residency Guidelines and is actively participating in Board Review activities if assigned:

No

Yes

The trainee is on track to meet the required 200 hours of conference time by the end of the academic year:

No

Yes

REQUESTDate 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 Nationwide Children’s website: www.nationwidechildrens.org/gme-policies-and-procedures.

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.

Resident/Fellow (Trainee) Moonlighting Request FormNOTICE: This Moonlighting Request Form must be submitted as soon as the moonlighting assignment has been made. Trainee First Name:

Trainee Last Name:

Email Address

PGY Level:

PGY1 PGY2 PGY3 PGY4

Residency/Fellowship Program:

Current Rotation:

PREREQUISITESThe Trainee has a current, unrestricted Ohio Medical License:

No

Yes

Trainee is NOT permitted to moonlight on an Ohio Training Certificate.The Trainee is here on a J-1 Visa:

No

Yes

Federal regulations prohibit trainees on J-1 Visas from working or receiving compensation for activities outside the approved training 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:

No

Yes

Trainees who have not fulfilled the obligations of the GME program are not permitted to moonlight.The Trainee seeks to moonlight as an independent practitioner:

No

Yes

If you answered ‘Yes’ to the previous question, has the Trainee been credentialed by the Medical Staff?:

No

Yes

MED PED RESIDENTS ONLYThe trainee has met acceptable levels in Medical Knowledge per Med-Peds Residency Guidelines and is actively participating in Board Review activities if assigned:

No

Yes

The trainee is on track to meet the required 200 hours of conference time by the end of the academic year:

No

Yes

REQUESTDate 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 Nationwide Children’s website: www.nationwidechildrens.org/gme-policies-and-procedures.

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.

Resident/Fellow (Trainee) Moonlighting Request FormNOTICE: This Moonlighting Request Form must be submitted as soon as the moonlighting assignment has been made. Trainee First Name:

Trainee Last Name:

Email Address

PGY Level:

PGY1 PGY2 PGY3 PGY4

Residency/Fellowship Program:

Current Rotation:

PREREQUISITESThe Trainee has a current, unrestricted Ohio Medical License:

No

Yes

Trainee is NOT permitted to moonlight on an Ohio Training Certificate.The Trainee is here on a J-1 Visa:

No

Yes

Federal regulations prohibit trainees on J-1 Visas from working or receiving compensation for activities outside the approved training 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:

No

Yes

Trainees who have not fulfilled the obligations of the GME program are not permitted to moonlight.The Trainee seeks to moonlight as an independent practitioner:

No

Yes

If you answered ‘Yes’ to the previous question, has the Trainee been credentialed by the Medical Staff?:

No

Yes

MED PED RESIDENTS ONLYThe trainee has met acceptable levels in Medical Knowledge per Med-Peds Residency Guidelines and is actively participating in Board Review activities if assigned:

No

Yes

The trainee is on track to meet the required 200 hours of conference time by the end of the academic year:

No

Yes

REQUESTDate 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 Nationwide Children’s website: www.nationwidechildrens.org/gme-policies-and-procedures.

Resident/Fellow (Trainee) Moonlighting Request Form

NOTICE:

This Moonlighting Request Form must be submitted as soon as the moonlighting assignment has been made.

PGY Level:

PGY1 PGY2 PGY3 PGY4

Residency/Fellowship Program:

Current Rotation:

PREREQUISITESThe Trainee has a current, unrestricted Ohio Medical License:

No

Yes

Trainee is NOT permitted to moonlight on an Ohio Training Certificate.The Trainee is here on a J-1 Visa:

No

Yes

Federal regulations prohibit trainees on J-1 Visas from working or receiving compensation for activities outside the approved training 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:

No

Yes

Trainees who have not fulfilled the obligations of the GME program are not permitted to moonlight.The Trainee seeks to moonlight as an independent practitioner:

No

Yes

If you answered ‘Yes’ to the previous question, has the Trainee been credentialed by the Medical Staff?:

No

Yes

MED PED RESIDENTS ONLYThe trainee has met acceptable levels in Medical Knowledge per Med-Peds Residency Guidelines and is actively participating in Board Review activities if assigned:

No

Yes

The trainee is on track to meet the required 200 hours of conference time by the end of the academic year:

No

Yes

REQUESTDate 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.

PREREQUISITES

Trainee is NOT permitted to moonlight on an Ohio Training Certificate.

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 Nationwide Children’s website: www.nationwidechildrens.org/gme-policies-and-procedures.

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.

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.

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.