Medical
Student Procedures
Students
arriving at LVHHN for the first time must contact the Division of Education,
via email, to Sherri_S.White at least
three weeks prior to the start of the rotation and provide the
following information:
Name
School / Year
*Social Security Number
*Date of Birth
Preferred E-Mail Address
Cell/Home Phone Number
Housing Required: Y / N
*SSN and DOB are required
for ID badge and computer access processing.
This process takes 3-5 business days; therefore, it is extremely
important that this information is provided to us at least three weeks prior to
a rotation.
Students will receive an
email notification with their arrival, housing and orientation information on
Thursday prior to the start of a rotation.
All
medical students reporting to LVHHN for a clerkship or elective rotation must provide
one form of picture identification to Security upon arrival. Students will then receive their LVHHN ID
badge, providing the student has contacted LVHHN with their personal
information well in advance.
In
addition, all students are required to bring a photo copy of their immunization
records and medical insurance ID card with them to orientation on the first day
of their rotation. The current
immunization requirements are attached.
Students who do not adhere to the above procedures may forfeit their
current rotation assignment. As always,
thank you for your cooperation in these matters.
Sherri
White
Division
of Education
17th
and Chew Streets,
(610)
969-2554
HEALTH CERTIFICATION FOR DIVISION OF
EDUCATION PROGRAMS
o Resident
NAME:______________________________________
o Medical Student
Social
Security Number _________________ o PA
Student
Department
or Program
__________________ o Nursing Student
o Other ______________________
Welcome to
DISEASES
|
IMMUNIZATION DATES* |
DOCUMENTED HISTORY OF DISEASE* |
TITERS* |
||||
Date
|
Result
|
||||||
|
Hepatitis
B (for
those with potential blood/body fluid contact) |
(1) |
(2) |
(3) |
|
|
(+) (-) |
|
|
Varicella (chickenpox) |
(1) |
(2) |
|
|
|
(+) (-) |
|
|
MMR |
(1) |
(2) |
|
|
|
(+) (-) |
|
|
Measles (rubeola) (Only 1 dose required if born before 1957) |
(1) |
(2) |
|
|
|
(+) (-) |
|
|
Mumps |
(1) |
|
|
|
|
(+) (-) |
|
|
Rubella |
(1) |
|
|
|
|
(+) (-) |
|
|
Diphtheria/Tetanus Not
required but please document last dose and update if necessary |
|
|
|
|
|
||
|
Other
Vaccines not
required but please document date if applicable |
BCG |
|
|
|
|
|
|
|
|
|
|
|
|
|
||
*Must have documentation of
appropriate number of immunizations, or documented history of disease or positive titer.
Tuberculosis: Two TB skin tests within 12
months prior to your start date at LVHHN, and one of which is within 3 months
of the start date:
Date #1:____/____/____ Result o (+) o (-)
Date #2:____/____/____ Result o (+) o (-)
Or if applicable
Date
of first positive TB skin test:
____/____/____ o
INH
Therapy o Yes o
No
Chest
x-ray within the past 6 months: ____/____/____ Result o nl o abnl
I hereby certify that___________________________________ is free from communicable diseases in the communicable state. This individual does not possess any health handicap or other physical limitation which would interfere with his or her ability to satisfactorily perform the duties to which assigned within the scope of duties normally performed in the role identified above. I also certify that the immunization/immunity/testing requirements, as listed above, have been fulfilled.
Health Care Provider’s Signature_____________________________
Health Care Provider’s Name (print)_________________________
Phone number_________________________________
Date:________________________________________
Visiting Residents
must return this form to: Kimberly
Cornwell,
Medical Student must return
this form to: Sherri White,
Nursing Student must
return form to: Donna Stout,
10/29/04
word/forms1/CEDShealthcertification