2014 – 2015
C R E I G H T O N U N I V E R S I T Y
LIABILITY INSURANCE
Moonlighting Activity Report
For House Staff Physicians
All moonlighting activities must be reported to the Chairman and Program Director. This form should be completed for any moonlighting activities being performed. This form is not intended for credentialing or privileges at any institution. Credentials and privileges are granted by the employer. The House Staff Physician agrees and acknowledges that this form is for informational purposes only. Any moonlighting activity he/she engages in is performed individually and not as an agent, direct or indirect, of Creighton University or any of its employees. He/she agrees to indemnify and hold the University and its employees harmless from any claims, cause of action, or damages of any type arising from such moonlighting activity.
Print or type information.
Name: ______
Dept.: ______
*** License Information ***
Copy of Permanent License is to be attached to the back of this document
Permanent Nebraska License Number: ______
Permanent Iowa License Number: ______
Other State License Number: ______
Name of State: ______
*** Moonlighting Activity ***
Include name of Institution, City and State
Location: Date(s) and/or Time Frame
______
______
______
Signature of the Chairman and Program Director indicates receipt of this reporting form for moonlighting activity. The House Staff Physician understands and acknowledges that the Chairman and Program Director have no involvement of any type of directing, controlling, supervising, reviewing, and/or credentialing the physician for any moonlighting activity and that the engagement in such activity by physician is at his/her sole risk.
______
Signature of Chairman Date
______
Signature of Program Director Date
______
Signature of House Staff Physician Date
Return COMPLETED original form to the GRADUATE MEDICAL EDUCATION OFFICE
Department should retain a photocopy in department file