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Paperwork instructions

Advocate Lutheran General Hospital
Medical Student Office
1775 W. Dempster St., 6 South
Park Ridge, IL 60068

Required forms:

Once a rotation is scheduled or approved, the following forms and information must be received by the Medical Student Office a minimum of four (4) weeks prior to the rotation start date. Information should be submitted via email. Students must follow-up with the coordinator to ensure paperwork has been received.

Rotation paperwork check lists

RFUMS, U of I Chicago, and Midwestern-CCOM:
  • Medical student information form
  • Confidentiality agreement
  • TB questionnaire (positive PPD/QFT only)
All other students:
  • Medical student information form
  • Medical and immunization clearance form
  • Confidentiality agreement
  • Letter of good standing
  • Attestation

Forms and instructions:

Medical student information form [PDF]

  • Must be completed for every rotation scheduled at an Advocate Health Care hospital ot medical center

Medical and immunization clearance form [PDF]

  • TB test – If TB test expires during a scheduled rotation, an updated test is required prior to the rotation start date. Positive TB test (>9) requires proof of negative chest x-ray (must be dated after positive TB test) and TB Questionnaire (must be completed for every rotation).
  • Mask Fit Test - Every student rotating on a clinical service must be fit tested for a Technol N-95 TB mask. The test date and mask size must be indicated on the medical 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.
  • Flu Vaccine – Students are required to be vaccinated for the current flu season for the rotation start dates from October 1 – April 30.
  • Students are required to sign the form to verify the accuracy of the information. 

Confidentiality agreement [PDF]

Attestation [PDF]

Letter of good standing

  • Must be on university or medical school stationery and be signed by the Office of Student Affairs.
  • Must verify student academic status, the medical school’s approval/authorization of the named elective and rotation dates, and the student evaluation requirements.
  • Must include verification of the following:
    • Criminal background check
    • OSHA/universal precautions training
    • HIPAA training
    • BLS/CPR training
    • Student health insurance coverage
    • Malpractice/liability insurance in the required minimum amounts of $1 million per occurrence/$3 million aggregate

Student video

  • You must watch the following video in full four (4) weeks prior to rotation. After watching the videos, please send a screen shot of the final registration pages and submit with your paperwork.