Dear - Welcome to Ann & Robert H. Lurie Children’s Hospital of Chicago

Prior to starting in your role with Lurie Children’s, you must provide certain health/immunization records to comply with hospital policies and other regulatory requirements. These records will be reviewed to ensure you satisfy these requirements by the Corporate Health Department of Northwestern Medical Physician Group on our behalf. Corporate Health will then send a clearance notice to your Lurie Children’s contact. Any follow up on missing documentation or other instructions will be provided to you by Corporate Health.

Your start date will be delayed if you do not complete and satisfy all the requirements.

Please follow the steps below as soon as possible for your records to be reviewed so you can begin your new role:

  1. Prepare copies of your health/immunization/blood titer records – It is required that you provide copies of the following records to be reviewed to satisfy these requirements. If you do not provide these documents, you will not be able to start your new role until you have done so.

Measles/mumps/rubella (MMR) proof of immunity is required.

Varicella (chicken pox) proof of immunityis required.

Any of the following documents will be accepted for measles/mumps/rubella (MMR) and varicella:

  • Official documentation of 2 each of measles/mumps/rubella (or 2 MMR’s), and 2 varicella vaccines.
  • Official documentation of lab work showing immunity to measles/mumps/rubella and varicella.

Influenza (flu) vaccination. Lurie Children’s has a mandatory flu vaccination policy. If your start date is during flu season, you are required to provide official documentation that you’ve received a flu vaccine this season. If your start date is not during flu season, you will be required to get a flu vaccine during the next flu vaccine period.

Tuberculosis (TB) tests. 2 TB skin tests (one within the past year and one within 90 days of starting), or Quantiferon Gold TB test or Tspot blood test within last 1 year. If you have a history of positive TB skin test, provide that documentation and a radiology report of a chest x-ray within the past year.

Hepatitis B not required but highly recommended if your role will be in a direct patient care area. If you do have this, proof of immunity or official documentation of the 3 series of immunizations.

Adult tetanus/diphtheria/pertussis (Tdap) vaccinationnot required but highly recommended if you will be providing direct patient care. If you do have this, proof of vaccination.

If you do not have any or all of these health records in your possession, you may be able to get copies from:

  • your doctor
  • your high school or college (if you are a current or recent student)
  • current or recent employer

If you don’t have records from these sources of any or all of these immunizations or tests, you will still need to obtain and provide the official documentation for these items. You can generally complete these tests at your doctor’s office or a local convenient care health center. You’ll be responsible for the cost of these tests which may be covered by a health insurance plan you may have.

  1. Complete the personal information form on the following page.
  1. Send a copy of this letter, your health records and personal information form via mail, fax or email to:

Mail: Susan Seidler, Medical Staff Office - #2, Lurie Children’s Hospital, 225 E. Chicago, Chicago, IL 60611

Fax:312-227-9636

Email:

  1. Questions, please contact: Northwestern Corporate Health at 312.926.8282 or

PERSONAL INFORMATION FORM

MD Observer/Rotating Trainee

Lurie Children’s Contact to Complete:

Lurie Children’s Contact Name
Sue Seidler / Department
Email Address
/ Phone
312-227-4322
Onboarding Individual’s Role
GME Coordinator / Start Date / Expected/Anticipated End Date

MD Observer/Rotating Resident to Complete:

Name (last, first, middle initial) print / Date of Birth / Last 4 DigitsOfSS#
Home Address City State Zip Code / Home Phone
Email Address / Work Phone / Cell Phone
Male
Female / Emergency Contact Name / Emergency Contact Phone
Do you have any physical limitations or disabilities which would impact your ability to perform your function or assignment? / No
Yes. If so, please describe
Do you have any medical conditions that should be known in order to provide safety for you while you perform your function/assignment to our hospital and our patients? / No
Yes. If so, please describe

______

MD Observer/Rotating ResidentSignatureDate

Please return this form with your health/immunization records.