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Forms & requirements for podiatry students

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 [PDF]

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

  • Medical and Immunization Clearance Form [PDF]

    • 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.

    • TB information must be current within one (1) calendar year of the rotation start date. If your TB test expires during your rotation you are required to get an updated test prior to the rotation star date. If you're current TB test was positive, proof of a negative chest x-ray or medical clearance is required. If you had a positive TB test in the past with a negative chest x-ray, a screening questionnaire completed within one year of your scheduled rotation is sufficient for clearance.

    • 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) [PDF]

  • Influenza Vaccination- Request for Medical Exemption [PDF]
  • Influenza Vaccination- Request for Religious Exemption [PDF]

  • Access Form [PDF]

    • 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