Lurie Children’s Hospital of Chicago Forms

NOTE: Only M4’s are scheduled for Otolaryngology @ Lurie Children’s Hospital(LCH)

• SSN / Date of Birth Release Form (completed @ orientation)
• LCH Corp Health Check List & Personal Information Form
• Medical Activity Observer Request Form

IMPORTANT NOTE:

• A TB skin test result/date must be documented within one year of rotation start date AND a TB skin test result/date must be documented within 90 days of  rotatation start date.

OR

• A TB quantiferon gold blood test result/date within one year of rotation start date.

If you do not meet these requirements, as well as, what is required on the checklist and immunization history form, your rotation may be cancelled, per the Hospital requirements.