Application for Osteopathic Elective Clerkship

Application for Osteopatic Elective Clerkship - Section II

McLaren Greater Lansing Application for Osteopathic Elective Clerkship - Section II
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Please Provide the following information on - (last, first, middle initial): *

The above named student is a student in good standing:

Yes

Comments:

They are approved to take the requested elective(s):

Yes

Comments:

They will be covered by liability insurance while rotating at McLaren Greater Lansing:

Yes

Comments:

Our records show this student has:

Personal health coverage which will be in effect during this protation:

Yes

Comments:

Completed required OSHA training in Universal Precautions within 12 month period proceding this elective:

Yes

Comments:

Had all recommended immunizations:

Yes

Comments:

Had a negative PPD skin test within the preceding 12 months:

Yes

Comments:

Had a serology test showing immunity to rubella:

Yes

Comments:

Received the hepatitis B vaccine series:

Yes

Comments:

Had a physician documented case of variecella OR has had a serolgy test showing immunity to varicella:

Yes

Comments:

Submit any other documents and a copy of the students immunization records to:
McLaren Greater Lansing
Medical Education
Attn: Gary Riley
401 W. Greenlawn Ave.
Lansing, MI 48910

Student Affairs Dean or Official (name and title):

Phone Number:

Email:

I agree that the above is true to the best of my knowledge, initial here: *

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