MSH & BI Moonlighting Request Form for Mid-Level Providers
This form is for moonlighting requests from PAs and residents in the Sinai Adult ED, Sinai Peds ED, Beth Israel Urgent Care, or Beth Israel Peds ED ONLY. It does NOT include Mount Sinai Queens. For questions about MSQ moonlighting, please contact Dr. Richard Leno at richard.leno@mountsinai.org.

DISCLAIMER: While the EM chiefs and PA chief 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. If you have any questions, please don't hesitate to ask PA chief or residency leadership at any time.

Your First and Last Name: *
Your answer
What type of mid-level are you? *
If you are a PGY1, you need permission from Kaush in order to moonlight. Please forward your approval email to sinaiemmoonlighting@googlegroups.com. Your shifts will be reviewed and approved once we receive this email.
Your preferred email address: *
Your answer
Which site are you requesting? *
FOR RESIDENTS ONLY: Which block are you requesting?
FOR RESIDENTS ONLY: Where are you working during this block?
Please CLEARLY indicate which DAY, SHIFT TYPE, AND TIME you are requesting. For instance: 4/7, Acute Swing, 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, Acute Swing, 2p-11p; 4/10, Intake, 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. *
Your answer
Do you have any additional comments regarding your request?
Your answer
Please review our Official Moonlighting Policies at https://goo.gl/k5DBfd. If you have any questions, please email sinaiemmoonlighting@googlegroups.com. Thank you!
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