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:
Comments:
They are approved to take the requested elective(s):
Comments:
They will be covered by liability insurance while rotating at McLaren Greater Lansing:
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Our records show this student has:
Personal health coverage which will be in effect during this protation:
Comments:
Completed required OSHA training in Universal Precautions within 12 month period proceding this elective:
Comments:
Had all recommended immunizations:
Comments:
Had a negative PPD skin test within the preceding 12 months:
Comments:
Had a serology test showing immunity to rubella: 
Comments:
Received the hepatitis B vaccine series:
Comments:
Had a physician documented case of variecella OR has had a serolgy test showing immunity to varicella:
Comments:
Comments:


Submit any other documents and a copy of the students immunication 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:

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