for NIH non-FTE MD Trainees Providing Patient Care (e.g.
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
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
NIH Trainee Outside Activity
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.
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: ______________
I am here on a Visa Yes
If Yes, my Visa Type is
Recommend Approval: Yes