Moonlighting Report Form

Name _________________________________  Block ________ Dates of Block _______________

I am authorized by the ROC to moonlight for _________ hours per week, at the following location(s) as long as total hours per week in any single week in the residency and at moonlighting do not exceed 80, and I am not on an inpatient ward, ICU, or CCU rotation, regardless of the total hours worked.

Location 1 _____________________________________________________

Location 2 _____________________________________________________

Location 3 ______________________________________________________

I certify that during the block just ended, I have moonlighted on the following schedule, reflected in the table below. I further certify that I have not worked more than 24 continuous hours during this period of time and that my total hours worked have not exceeded 80 in any single week. I understand that my primary work obligation is to my residency program and my education.

Attach a copy of the official schedule.

___________________________________________________________  ___________________

Signature                                                                                                          Date

PD Initial [       ]