Instructions

This form is required for NIH Trainees requesting approval to provide patient care as an outside activity (e.g. moonlighting). Please read, complete, and print this page. After your mentor/supervisor signs, attach this document to your Guidelines Review.

Summary Guidance

NIH employees are prohibited from engaging in an outside activity that is part of an ongoing research project conducted or funded by the NIH; may not establish a private practice relationship with a current or recently discharged NIH patient or subject of an NIH-conducted or NIH-funded clinical trial or protocol; and may not personally refer private practice patients to the NIH. Additionally, employees are prohibited from accepting compensation for employment in connection with an activity funded by HHS.

Although your status is non NIH employee, you should still be mindful of these prohibitions You are further reminded that engaging in outside clinical practice must be performed on your own time and without the use of NIH resources.

NIH Trainee Outside Activity Information

Name (print):

I am not a Clinical Fellow. However I wish to engage in and receive compensation for the outside practice of medicine that involves the provision of care, treatment, or other health-related services to individual patients.

Work Hours

In accordance with the OIR NIH Policy on Outside Activities this outside activity will occur at times when I have no obligations related to official duties at NIH, i.e., weekends, evenings. I certify this will not impinge upon my commitment to my research project or supervisor.

Initial here to confirm that you have read the NIH policy: ______________

VISA Information

I am here on a Visa Yes No

If Yes, my Visa Type is

Supervisor's Review (Required)

Supervisor Name

Email Address

Recommend Approval: Yes No

Signature: Date: