Many have asked what we send out for rotations.

This is what we mean by ‘your paperwork’ or a ‘rotation

packet’.

For the core rotations set up through the ‘picks’ process in the fall, we do not send an individual Letter of Good
Standing (LGS)—the affiliates receive that info in a report form as well as an individual immunization sheet for
each student.

Standard Rotation Packet—this is what we send for EVERY rotation that you enter in the portal.
everything in red is specific to the ROTATION and STUDENT
Please read the sample so you know what is included

1. Letter of Good Standing [LGS] (sample below—scroll down)

2. Acceptance letter for preceptor to sign and return—sample below (no penalty if they do not return)
3. Immunization page (see below) which lists dates for:
 DTP
 Adult Tetanus
 Polio
 HepB
 measles
 mumps
 rubella
 PPD
 drug screen
 background checks
 OSHA
 HIPAA
 your health ins
 BLS
 ACLS
4. Clinical Clerkship Student Evaluation Form (also available in the Clinical Handbook)
5. LECOM’s Certificate of Self-Insurance (liability insurance)
6. CME credit form--for the preceptor to fill out if he/she wants credits submitted to AOA

PLEASE NOTE: Except for family medicine rotations and ‘office only’ electives, students should contact the
Medical Education Office of the hospital to set up an elective/selective. The rotation packet is sent directly
to the ME office, not to the attending.
Today’s date

YOUR
Name of contact
PHOTO
Name of Site
HERE
Address of Site
City State Zip

The following MS4 student is in good standing at the Lake Erie College of Osteopathic Medicine
(LECOM), Erie Campus and has the Clinical Education Department’s approval to participate in the
following rotation at your facility.

Student: Student Name

Phone Number(s): phone number we have on file (notify REGISTRAR if you change it!)
Email Address: student@lecom.edu
Rotation: sample: MS4 Clinical Elective I Cardiology
Dates: sample: 7/28/2008 to 8/22/2008

LECOM does not give out Social Security Number, address or birth date information. If you require
additional information on this student, please contact him or her using the email address and phone
numbers listed above.

Immunizations including PPD are current and enclosed. This student has met HIPAA and
OSHA requirements. A criminal background check is on file.

Liability insurance coverage provided: Healthcare Provider Professional Liability under

the Self-Insurance Program
Housing Request: Yes/No

If you have any questions, please contact the Office of Clinical Education at (814) 866-8126,
(814) 860-5126 or (814) 866-8153.

Sincerely,

Regan Shabloski, D.O.

Associate Dean of Clinical Education
May 9, 2018

Regan Shabloski, D.O. YOUR

Associate Dean of Clinical Education PHOTO
Lake Erie College of Osteopathic Medicine HERE
1858 West Grandview Boulevard
Erie, PA 16509
Re: Student Name
Rotation Dates: Ex: 7/28/2008 to 8/22/2008
Dear Doctor Shabloski: Rotation: Ex: MS4 Clinical Elective I Cardiology

I agree to supervise the above-named MS4 medical student from the LECOM Erie Campus doing a
rotation during the dates shown above. I agree to evaluate the student using the Clinical Clerkship
Evaluation form(s) provided by LECOM and am aware that this rotation site will be evaluated by the
student.

Name: ____________________________M.D./D.O._______________________________________
(Please Print) (Circle One) (Signature) (Date)

Enter rotation site corrections below:

Name of Site
Address:
Address of Site

Phone:
Board Certification Number (if applicable): __________________________________________
Date: __________________ Phone: __________________________
If you have privileges at a facility and they need to be notified that the student will accompany you,
please provide the appropriate information below:
Name: _____________________________________ Position: ______________________

Address: _____________________________________________________________________

_____________________________________________________________________

Telephone: _______________________________ Fax: _______________________________

Please fax this form back to: 814-866-8401

L E C O M Immunization Report – Erie Campus
Name: Student Name Program: Osteopathic
Class: 2011
Vaccines: Completed Dates
1. 2. 3. . 4. .
DTP xx/date/xx xx/date/xx xx/date/xx xx/date/xx

Tdap (Adacel) 1.
xx/date/xx Td 1. .
xx/date/xx 2.

(Tetanus/diphtheria)
1. 2. 3. 4. .
Polio (OPV/IPV) xx/date/xx xx/date/xx xx/date/xx xx/date/xx Boosters:

Polio Notes:
1. 2. 3.
Hepatitis B xx/date/xx xx/date/xx xx/date/xx
1. . 2. . 3.
MMR xx/date/xx xx/date/xx
1. 2.
Varicella Had Chickenpox:
1. 2. .
PPD xx/date/xx xx/date/xx TestType: 2-Step Mantoux Result: Negative
1. 2. .
Annual PPD xx/date/xx xx/date/xx Test Type: 1-Step Mantoux Result: Negative

LAB DOCUMENTATION IS REQUIRED FOR ALL TITERS

Background Check OSHA Date Insurance
Titer: If a titer is negative or equivocal, proper Date (Verified) Effective
vaccines must be given as noted below with Date
repeat titer 6-8 weeks after last vaccine. Date Result
xx/date/xx xx/date/xx xx/date/xx
.
Varicella IgG xx/date/xx Positive
PA Access to Criminal CPR/BLS HIPAA Date
.
Rubella IgG xx/date/xx Positive History (PATCH)
xx/date/xx xx/date/xx xx/date/xx
.
Rubeola IgG xx/date/xx Positive
PA Child Abuse FBI Finger
Mumps IgG .
xx/date/xx Positive CPR/ACLS
History Clearance Print
xx/date/xx xx/date/xx xx/date/xx
.
Hepatitis B IgG xx/date/xx Positive

Vaccines: Completed Dates

Varicella: 2 1. 2.
vaccines 4 weeks Boosters:
apart and a
repeated titer Repeat Date: Results:
Titer: Non-Responder (Y/N):
Rubella: 1 vaccine Boosters: 1.
Results:
and a repeated titer
Repeat
Date: Non-Responder (Y/N):
Titer:
Rubeola: 2 Boosters: 1. 2.
vaccines 4 weeks
apart and a Date: Results:
Repeat
repeated titer
Titer: Non-Responder (Y/N):

Mumps: 1 vaccine Boosters: 1.

Results:
and a repeated titer
Repeat
Date: Non-Responder (Y/N):
Titer:
Hepatitis B: 3 Boosters: 1. 2. 3.
vaccines and a
repeated titer 6 – 8 Date: Results:
Repeat
weeks later
Titer: Non-Responder (Y/N):

10 Panel Urine Drug Screening - Lab Documentation Required Date: xx/date/xx

As a licensed health care provider, I certify the above information is true and accurate to the best of my knowledge.

signature
Regan Shabloski, D.O. Date: May 9, 2018
Envelope address
If you give us the wrong info . . . the site will not receive