Forms & requirements for physician assistant students

Once a rotation is scheduled or approved, the following forms and information must be
received by the designated site a minimum of two (2) weeks prior to the rotation start date.
Information can be submitted via email, fax, or postal service to the rotating location.
Students must follow up with their program 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 two (2) weeks prior to the start of the rotation.

Forms

• Physician assistant student information form [PDF]
• Must be completed for every rotation scheduled at an Advocate hospital or
  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.
• 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 [PDF]
• Access form [PDF]
• Care connection/confidentiality form

Required information

• Evidence of completed criminal background check – supplied by the university
  physician assistant program to site coordinator
• Evidence/verification of OSHA/Universal Precautions Training – supplied by the
  university physician assistant program to site coordinator
• Evidence/verification of HIPAA training – supplied by the university physician assistant
  program to site coordinator
• Copy of BLS and or ACLS certification (as applicable)