Moonlighting Activity Request | UAMS Graduate Medical Education

Prior to completing this form, please review UAMS COM GMEC 3.300 Moonlighting Policy. This form must be filled out by either the Program Director or Program Coordinator.

In order to complete this process, you will need to:

Download the Resident/Fellow Acknowledgment Form, obtain signatures and upload the signed form.
You must contact the Insurance and Judicial Coordinator at ADean2@uams.edu to ensure there are no concerns related to resident’s/fellow’s liability insurance coverage for this moonlighting activity. Upload email correspondence AND documented proof of one of the following:
- Individual liability of insurance (UAMS liability insurance does NOT cover external moonlighting activities.)
- Verification of liability insurance coverage from outside employer. Must be on letterhead.
- Certificate of liability coverage from outside employer.
For internal moonlighting requests only, upload documentation showing approval from department business administrator or their designee for the requested moonlighting activity.
- It is the responsibility of the department to ensure Moonlighting pay and UAMS salary does not exceed the Arkansas State line-item maximum ($97,605)

H1B Visa holders: Moonlighting activities may require an amendment to visa status. Prior to submitting request, please contact UAMS Immigration Services at askImmigration@uams.edu to inquire about the process.

Residents and fellows are NOT authorized to begin moonlighting until Program Director has received approval from the Designated Institutional Official. The GME Office will provide confirmation of the approval to the program.

Please allow up to THREE weeks for the processing of Moonlighting requests.

Moonlighting Activity Request Form

Name of Program Director or Program Coordinator Submitting Request(Required)

First Last

Training Program(Required)

Is this request for a group of trainees or an individual trainee?

Group

Individual

List Each Individual of the Group(Required)

Trainee Name

PGY Level

Are they a US citizen?

Visa Status if not US citizen

Medical License Number

Expiration Date

Federal DEA Number

Expiration Date

Trainee's Name(Required)

First Last

Email(Required)

PGY Level(Required)

Are they a US Citizen?(Required)

Yes

What is their Visa status?(Required)

Medical License Number(Required)

Expiration Date(Required)

Federal DEA Number(Required)

Expiration Date(Required)

Moonlighting Information

Moonlighting Type(Required)

Internal

External

Upload documentation of internal Moonlighting funding source:

Max. file size: 15 MB.

Liability Insurance from outside employer:

Max. file size: 15 MB.

Separate from my duties as a housestaff officer at UAMS, I request to be employed for the academic year selected below at the following location.(Required)

Approval is granted for 12 months or less during a single academic year (July 1 – June 30)

Name of Location for Moonlighting Activity(Required)

Administrative Contact Name for Moonlighting Activity(Required)

First Last

Administrative Contact Phone Number(Required)

Administrative Contact Email(Required)

Provide detailed description of duties that will be provided under Moonlighting Activity.(Required)

Provide details of proposed moonlighting work hours during a typical month.

Ex: number of times /day moonlighting will occur, number of hours worked during each moonlighting activity.

List Your External Funding Source(Required)

Upload Documentation of Internal Funding Approval(Required)

from the department business administrator

Max. file size: 15 MB.

Upload Documentation of Liability Insurance from outside employer AND correspondence with the Insurance and Judicial Coordinator.(Required)

You must contact the Insurance and Judicial Coordinator at ADean2@uams.edu to ensure there are no concerns related to resident’s/fellow’s liability insurance coverage for this moonlighting activity. Upload email correspondence AND documented proof of one of the following:

Individual liability of insurance (UAMS liability insurance does NOT cover external moonlighting activities.)
Verification of liability insurance coverage from outside employer. Must be on letterhead.
Certificate of liability coverage from outside employer.

Drop files here or

Max. file size: 15 MB, Max. files: 2.

Upload Program-Specific Moonlighting Policy(Required)

Max. file size: 15 MB.

Upload Signed Resident/Fellow Acknowledgement of Policy Document(Required)

from the Resident/Fellow

Max. file size: 15 MB.

Please allow up to three weeks for the processing of Moonlighting requests.