BI Adult ED moonlighting request form
This form is for moonlighting requests for residents in the MS Beth Israel Adult ED ONLY. For questions please contact JD Ditkowsky at jaredditko@gmail.com

Please review our Official Moonlighting Policies at https://goo.gl/k5DBfd.

DISCLAIMER: While the EM chiefs will gladly update the schedule with your moonlighting shifts, please note that you are individually responsible for showing up to your regular clinical shifts as well as your moonlighting shifts. If you fail to show up for any reason other than sickness or emergencies, you will be held personally accountable. Before you make a moonlighting request, please check your transitions and duty hours carefully, and make sure you understand the penalties involved with missing a shift or a sick call activation. All the rules can be found in the Survival Guide - Official Residency Policies & Requirements (link above). If you have any questions, please don't hesitate to ask residency leadership at any time.

If you are a PGY1, you need permission from Elaine in order to moonlight. Please forward your approval email to jaredditko@gmail.com. Your shifts will be reviewed and approved once we receive this email.
Your first and last name *
Your preferred email address *
Level *
Which block are you requesting?
Where are you working during this block?
Please CLEARLY indicate which DAY, SHIFT TYPE, AND TIME you are requesting. For instance: 4/7, Blue pod, 2p-11p. If you are requesting multiple shifts, please separate them by indicating the day, shift type, and time for EACH request. For instance: 4/7, blue pod, 2p-11p; Orange pod, 2p-11p. Failure to follow this format will result in delays to approve your moonlighting shifts, and you may lose your shift to another mid-level as a result.
Additional comments?
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