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PLEASE NOTE NEW INFORMATION
Effective 10/1/2013, once a rotation is scheduled or approved, the following forms and information must be received by the Site/Department Student Coordinator a minimum of FOUR (4) weeks prior to the rotation start date.  Information can be submitted via e-mail, fax or postal service to the rotating location (See Site Specific Information).  Students must follow-up with the Coordinator to ensure paperwork has been received and processed. 

ROTATIONS WILL BE CANCELLED IF FORMS AND INFORMATION ARE NOT COMPLETE AND APPROVED A MINIMUM OF FOUR (4) WEEKS PRIOR TO THE START OF THE ROTATION.

Forms

  • Student Information Form

    • Must be completed for EVERY rotation scheduled at an Advocate Illinois Masonic Medical Center

  • Medical and Immunization Clearance Form

    • Vaccination/Immunity Status- student must indicate the date of the immunity titer and circle the result. If no titer, please indicate vaccination dates as listed.

    • Rotating Residents - TB documentation must be current within 1 calendar year. Positive TB test requires proof of negative chest x-ray (valid for 2 calendar years), medical clearance or screening questionnaire (valid for 1 calendar year).

    • Medical Students - If TB test expires during rotation, an updated test prior to the rotation start date is required. Positive TB test requires proof of negative chest x-ray (valid for 2 calendar years), medical clearance or screening questionnaire (valid for 1 calendar year).

    • Every student, rotating on a clinical service, must be fit tested for a TB mask. The date and type of mask must be indicated on the medical clearance form.

    • The student is required to sign the form to verify the accuracy of the information.

  • TB Questionnaire (as applicable)

  • Access Form

    • Care Connection/Confidentiality Form

Required Information

  • Evidence of completed Criminal Background check--supplied by the university to the Medical Education Department Student Coordinator

  • Evidence/verification of OSHA/Universal Precautions Training--supplied by the university to the Medical Education Department Student Coordinator

  • Evidence/verification of HIPAA training--supplied by the university to the Medical Education Department Student Coordinator.


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