3rd Year Clerkship Processing Application The Medical Student Rotation Program teaches students/ residents essential clinical and practical skills. Participating students rotate with Peconic Bay Medical Center and participating siteŐs faculty and residents in a variety of areas. Rotation Requirements The following is required in order to begin your rotation. Please make sure all supporting documents are sent to Kimberly Ranagan at least one month prior to your rotation. Medical Student Prerequisites All prerequisites must be met before you are approved for a rotation. This includes the completion of all core rotations and status as a final year medical student when you are scheduled to participate in the rotation. Health Requirements The Office of Medical Education requires medical students to provide proof of the following immunizations: Ą Proof of Varicella Rubella, Rubella immunity (serology) Ą Proof of Hepatitis B immunity (serology) Ą Annual Tuberculosis Screening Ą Annual Flu vaccine (during flu season) Ą Proof of T-Dap (within 10 years) Ą Proof of COVID-19 Vaccination All students must provide health documentation in order to begin a scheduled rotation. Parking On the first day of your rotation please park in the visitorŐs lot located across the street from the hospital: 1 Heroes Way, Riverhead, NY 11901. Once cleared through security your badge will provide access to the employee lot located off Middle Road in Riverhead. Further parking directions to be distributed on the first day of the student rotation. White Coats Be sure to bring your white coat; it is required that you wear one while on the premises of Peconic Bay Medical Center or any off-site clinics. Miscellaneous Students are expected to bring their own diagnostic equipment and textbooks. Trainee Information: Name Gender: . Female . Male . Other Address City State Zip Home Phone Cell Phone Email Address (preferred) or Emergency Contact Name: ______ Relationship: ________________________ Phone: Have you rotated at Peconic Bay Medical Center or another Northwell Hospital? Yes or No If you answered yes, what was your universal ID assigned to you for your rotation?__________________________________________________________________________________ I certify that the above information is correct to the best of my knowledge at the date of this application. I also understand that completing this application does not guarantee an offer of placement by Peconic Bay Medical Center. ________________________________________________ ____________________ Signature of Applicant Date . Photo ID- DriverŐs License or Passport . Computer Access Forms . HIPAA Acknowledgement Form . Health Information- Immunizations Including: Ą Proof of Varicella Rubella, Rubella immunity Ą Proof of Hepatitis B immunity Ą Annual Tuberculosis Screening Ą Annual Flu vaccine (during flu season) Ą T-Dap Ą COVID 19 Vaccine . Surgery ONLY Ą ilearn scrub modules