Fillable Housestaff Request 5 7-20 Final 1

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Housestaff Request 5 7-20 Final 1

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HHC 799 (May 20)
N
EW YORK CITY HEALTH + HOSPITALS
Housestaff Request
General Information
Facility:
Clinical Service:
Housestaff Officer Information
First Name:
Last Name:
Employee ID:
Job Class:
Date of Coverage:
/
/
Payment Information
*If you are claiming multiple payments, please complete a separate request form for each.
Please check one box only
Type of On-call/coverage
Code
Amount
OCE
$418
OCW
$558
OCS
$210
CCC
$418
CC1
$418
CC2
$418
CCC
$558
CC1
$558
CC2
$558
Scheduled Holiday Worked Pilot (More than 50% of shift)
$200/per Shift
Holiday Worked: ___________________ (New Year’s Day, Martin Luther King Jr. Day, Washington’s Birthday,
Memorial Day, Labor Day, Independence Day, Thanksgiving Day, Christmas Day).
If requesting on-call compensation, please complete the following for absent housestaff officer:
First Name: Last Name:
Dates of Absence: / / to / /
If I am claiming compensation for critical care coverage, I hereby certify that such hours are in addition to my
regular residency hours
Housestaff Officer Signature:
Approval
(to be completed by Program Director/Chief Resident)
Name: Title:
Signature:
Date: / /
Note A copy of department/service on-call schedule must be attached for payment to be made.
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Housestaff Request 5 7-20 Final 1

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Completed 15 July 2020

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