1720 Cesar E. Chavez Avenue

1720 Cesar E. Chavez Avenue

Medical Education / LLU Dept

1720 Cesar E. Chavez Avenue

Los Angeles, CA 90033

Ph: 323-881-8840

PODIATRY STUDENT ROTATION REQUEST FORM

White Memorial Medical Center/LLUSM – Los Angeles Campus Site

Name: ______M _____ F _____ Email: ______

Address: ______City: ______State: ______Zip Code: ______

Home Number: (____) ______-______Cell Phone Number: (____) ______-______

Medical Status: ______4th Year

U.S. Podiatric Medical School you are currently attending: ______

Expected date of graduation: ______

Rotation Dates: ____/____/____ to ____/____/____WMMC follows the National Clerkship Calendar

Submit your application and all required documents to . Fax copies will not be accepted.

  1. There is a $25 fee per rotation. Please mail your check to White Memorial Medical Center, Medical Education/LLU Associate Deans Office, Attn: Pattie Sandoval, 1720 Cesar E. Chavez, Los Angeles, CA, 90033, and make the check payable to “WMMC”.
  2. A letter from your school stating the following:
  • You are in “Good Standing”
  • That indicates an actual amount for general liability and professional liability insurance ($1 million in occurrence and $3 million annual aggregate) as well as accidental insurance.
  • HIPPA compliant with date of training or certificate.
  • This section must be written in this manner or it will not be acceptable:The student has completed a background check and has cleared a nationwide/county criminal record, by Date of Birth and Social Security through our (department name). The student’s background check was conducted on (date), by (Source Name). Thebackground check must be current within 2 years. DO NOT SUBMIT A COPY OF YOUR BACKGROUND CHECK.
  1. A Health Clearance Form that must be completed by an authorized clinician and sealed with the clinic stamp. (Please view the Health Clearance Form for further instructions)
  2. A copy of your current BLS and ACLS.
  3. A copy of your Health Insurance Card. (front and back)
  4. All required documentation must be sent by e-mail, faxed copies will not be accepted.

NOTE:

  • Meals will be provided for you in the hospital cafeteria during your rotation.
  • Checking in may only be done during working business hours. If arrangements need to be made, please contact me at 323-881-8840
  • A $10 deposit is required at the time of check-in: the deposit is refundable (Further information on the purpose of these deposit will be given on your first day of orientation, if accepted).

Housing is only provided to students that attend a medical school 50 miles or more away from White Memorial Medical Center (if available, no exceptions). Outpatient rotations are not a part of the housing accommodations.

Please Indicate: ______Yes, I need housing ______No, I do not need housing

Dear Podiatry Student,

In order to begin your rotation as scheduled at White Memorial Medical Center, you must complete the following requirements listed below. Please read all the information carefully as you are responsible for ensuring that all requirements are fulfilled. If you have any questions or concerns email me or contact me at 323-881-8840.

Deans Office

The Deans Office will send the following required information in a letter format:

  • A letter of “Good Standing”
  • Professional/Malpractice Liability Insurance $1 million per occurrence/$3 million Annual Aggregate
  • Hippa Compliant Dates
  • BLS & ACLS must be current (submit copies)
  • Mask Fit Test completion date
  • Background Check Certificate (Please read the background check information process below)
  • Immunizations and Titers
  • Tb Skin Test – current within one year. If you had a positive PPD, you are required to submit a copy of a current chest x-ray within 1 year.
  • Titers
  • MMR titer
  • Varicella titer
  • Hep B titer
  • Flu Vaccine– A flu vaccine is mandatory. If the flu vaccine is declined, you will be required to wear a mask on all patient care areas at all times, no exceptions. The flu vaccine is also available at the White. However, you must contact me to check on availability.
  • Td/Tdap – It is not required, but recommended.

Background Check

A current background check within 2 years is mandated. If your background check is not current, log onto your registration portal and update your background check. Send a copy of your receipt to . Do not wait until the last minute to update your background check as it may take one week to complete your request. If I do not receive a receipt of completion with a password, contact Rosalyn Hamilton at , or 909-558-4729 (please “CC” me to keep me posted).

Important Notice

You will not be able to begin your rotation as scheduled, if I do not have all requirements submitted. As soon as you receive this letter begin the process. Failure to complete the above requirements will result in the following:

  • Your school coordinator will be contacted (Deans Office)
  • You will be sent home and will not be able to return on site until cleared by the WMMC LLU Associate Dean Office
  • You will be required to make-up days missed

Once again, if you have any questions or concerns email me or contact me at 323-881-8840.

Thank you for your cooperation

Patricia Sandoval

Medical Student Coordinator/MITHS Assistant

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