Extra Shifts for Pay

Extra Shifts for Pay

Please complete the following form to request or record an extra shift for a resident or fellow in accordance with GME's Extra Shifts Policy.

This form may be completed by the Program Director, Program Coordinator, resident/fellow, or other administrator.

Shifts worked at Eskenazi MUST be requested and approved before the shift date. Coverage changes and last-minute requests should include a comment regarding the situation. If the shift is fully department-funded (meaning EMG will NOT be invoiced), please note this in the comments.

For shifts worked at any other locations, it is permissible to complete this form as post hoc confirmation of the shift. In those instances, submission of this form will serve as confirmation of the shift in lieu of an automated email request.

Residents and fellows are permitted to work up to 2 shifts per calendar month and up to a total or 20 per academic year to remain in compliance with the policy.

If you need to provide additional context or clarification, please feel free to use the "Notes/Comments" field at the end of this form.

Resident/Fellow Details

Which program is the trainee in?*

Please indicate the current training program for this resident or fellow, regardless of the shift/service name they will be covering (we will obtain the shift/service name later in this form).

Select or enter value

Resident/Fellow Last Name*

Resident/Fellow First Name*

PGY Level*

NOTE: Must be PGY 2 or higher to participate in this program.

Employee ID #*

If employee ID # is not known, please place alternative text in this field (e.g., "n/a", "unknown", etc.).

Resident/Fellow's email address*

This email address will receive the request for confirmation of hours as well as confirmation of payment processing.

Visa Status*

NOTE: J-1 visa holders are not eligible to participate in this program.

Select

Shift Start Date*

Shift Reassignment

If the person working this shift will be working INSTEAD of the person originally signed up for this shift, you will be asked to provide the name of the person currently assigned to the shift.

Shift Reassignment*

Is this individual taking the place of the person originally approved to work this shift?

Yes

No

Original person covering the shift:*

Who was originally scheduled to cover this shift? (enter first and last name)

Shift Details

Type of shift*

Please indicate whether this shift will contain in-hospital call, home call, or a combination of both.

In-Hospital

Home Call

Both

To be determined

Hospital hosting extra shift*

Select or enter value

Service hosting extra shift*

Total # of planned hours*

NOTE: only the approved # of hours is reimbursable. If this individual works a shift greater than the number of approved hours, the department will be responsible for funding the difference.

# planned hours - in-hospital

# planned hours - home call

Hourly Pay Rate for in-hospital hours*

Compensation for residents may not exceed $90 per hour.

Compensation for fellows may not exceed $110 per hour.

If the compensation planned for this shift differs from the program's typical compensation structure, please provide a comment at the bottom of this form with details.

Hourly Pay Rate for home call hours

Shift Already Worked - Confirmation Details

This section only appears for shifts entered AFTER the planned shift date. Please verify the number of hours spent on call in the hospital AND at home.

If home call hours are not applicable, please document a 0 in the home call field.

Submitting worked hours through this form will mark the shift as confirmed. Because of this, the resident or fellow will not receive an email asking for confirmation of hours.

In all cases, the resident or fellow and program coordinator will still receive notifications once the payment processing has begun and again once the payment is confirmed.

Was this shift worked?*

If this shift was canceled, please select "No", otherwise select "Yes".

Select

Actual # hours worked - home call*

If no home call hours were planned or worked, please document 0 in this field.

Actual # hours worked - in-hospital*

NEW SECTION: Form Submitter Information

This section has been added to help us better understand each program's process and assist with timely troubleshooting as needed.

Who is submitting this form?*

Please indicate which option best represents the individual submitting this form today.

Resident/Fellow Self-Submission

Chief Resident/Co-Resident/Co-Fellow

Program Coordinator

Program Director

Associate Program Director/Other Faculty

Hospital scheduling personnel/SLA

Other

Name of person submitting this form*

Email address of person submitting this form

Notes/Comments

Send me a copy of my responses

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