Extra Duty Form

Please complete the form below and have your Program director to sign it.

If you are not with your program director by the the time you are completing the application, please use "save and return" so you will get an email with a link that your program director can access it, forward the email to your program director and have him sign it and submit.

After you both sign it and submit it, you should receive an email with approval of your application shortly.

Thank you!

For any question:

nour.tashtish@uhhospitals.org

APPENDIX A
CHECK WITH GME OFFICE TO ENSURE YOU ARE USING THE CURRENT FORM APPLICATION FOR INTERNAL EXTRA DUTY WITH PAY

This Application is based upon a template drafted by the UH Law Department as approved in Sept 2013. Blank lines should be appropriately filled in but the language cannot be modified in any way without Law Department approval. This template, if unchanged. does not require UH Law Department Approval. Each fully executed Application should be saved with each Residents employment file, a copy sent to the GME office, and a copy uploaded to UH's then current contract management system as articulated in the applicable UH policy.

Name of the Site:
UH Cleveland Medical Center

Site Address:
11100 Euclid ave, Cleveland, OH 44106

Salary/Pay: $ per hour:
80$

Dates of extra duties:

7/1/2018 Through 6/30/2019

Covering Admissions (SHD, LHD) to Internal Medicine Inpatient Service

Name

* must provide value

Employee ID:

* must provide value

Email:

* must provide value

Resident/Fellow:

* must provide value

Resident

Fellow

reset

Level Of Training (PGY)

* must provide value

Training Program:

* must provide value

Ohio License:

* must provide value

DEA:

* must provide value

On Visa:

* must provide value

Yes

reset

Extra Duty that is not properly approved can result in the immediate termination of the Resident from their Training Program, and inappropriate approval of Extra Duty by the Program Director may also result in appropriate discipline of the Program Director in accordance with the applicable UH policies. Internal Extra Duty is considered a part of a Resident's contract of employment with UH.
By signing below, the Program Director certifies that they have confirmed with the UH HS Authorized representative (if other than themselves) that the Extra Duty pay is consistent with Fair Market Value in accordance with the requirements of UH HS Policy PT-S.

Resident/Fellow Signature:

* must provide value

Add signature

Program Director Name:

* must provide value

Program Director Signature:

* must provide value

Add signature

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.