Dear Applicant, Requirements:

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1 John H. Stroger, Jr. Hospital of Cook County Department of Planning, Education and Research Hektoen Building, 627 S. Wood St., Room 832A Chicago, Illinois / Cook County Bureau of Health Services Dear Applicant, Welcome to John Stroger Hospital! Enclosed is an application for an elective rotation at John H. Stroger, Jr. Hospital of Cook County. You should have the application approved by both your home institution s residency / fellowship director and by the program director at Stroger Hospital. Please bring the signed application with you, along with the required documents listed below, when you report to our office for an ID badge. Requirements: Approved application for an elective rotation Copy of your current medical license Copy of your current ACLS card (PGY 2s and above) Copy of professional liability insurance (see attached details) You must attend the BSIS infection control class, or show proof of attendance within the year (cannot expire during your rotation). Successful completion of an Orientation module and exam (must be renewed annually). Certificate of compliance health form (please see attached for specific requirements) ECFMG certificate (if foreign medical graduate) Proof of a Criminal Background Check if you are in a residency outside of Illinois You cannot be issued an ID badge until you meet all requirements. PLEASE NOTE: The Department of Human Resources issues ID badges within one week of your start date, and only between the hours of 8:30am and 2:30pm. Contact information: Stroger Hospital of Cook County Department of Planning, Education and Research 627 S. Wood St., 8 th Floor Chicago, IL Phone: 312/ Fax: 312/ Website: (choose the option Application for Resident Rotations ) Please feel free to contact us if you have questions.

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4 John H. Stroger, Jr. Hospital of Cook County Department of Planning, Education and Research Hektoen Building, 627 S. Wood St., Room 832A Chicago, Illinois / Cook County Bureau of Health Services TO: FROM: RE: Residency Program Directors Medical School Deans Directors and Nursing Allied Health Programs John O Brien, M.D. Director, Planning, Education and Research ANNUAL BSIS (INFECTION CONTROL) PROGRAM A REMINDER NOTICE As providers for extremely sick patients, we are mindful of the need to protect them and ourselves from the spread of infectious diseases. All employees, rotating physicians and students must be educated annually regarding their risk of exposure to bloodborne and airborne pathogens and appropriate precautions to reduce these risks (also known as BSIS education, Body Substance Isolation system). Residents and students rotating to Stroger Hospital are required to attend BSIS education before beginning a rotation. BSIS sessions are conducted by the Department of Planning, Education and Research each Monday and Wednesday morning, from 8:30 a.m. to 10:00 a.m. Individuals should report to Room 831 in the Hektoen Building, 627 S. Wood St., 8 th floor. Alternatively, you can complete the online course available through our web site (INTRAnet only). For your convenience, we have a terminal available in our office. If you have any questions, please feel free to contact our office at (312) cc: Chairman, Infection Control Committee

5 PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS If there is not a formalized agreement between your institution and Stroger Hosptial, the following professional liability insurance requirements must be submitted as part of your application for an elective rotation at Stroger Hospital: A Certificate of Insurance indicating the coverage to be in effect. Do not submit a copy of the insurance policy itself. The Certificate of Insurance must state that the insurance in effect will not be canceled or modified without thirty (30) days prior notice to Stroger Hospital. Minimum amounts of coverage are one million dollars per occurrence, and three million dollars aggregate. Your application will not be considered approved until the above requirements are met, therefore please include the certificate with your application.

6 Summary of Requirements on the Certificate of Compliance Health Form Documentation of a 2-step tuberculin test, including dates and results. If the 2-step test is more than one year old, provide documentation of tuberculin test within one year of the rotation. Description of a two-step tuberculin skin test: It will take a minimum of 10 days to complete the testing. Place the first test and read hours later. It is advised that within one to three weeks after placement of a negative first test, the 2 nd test be placed. Again, the test is to be read hours after placement. A TST Step 2 test placed greater than 90 days after a TST Step 1 will not be accepted. Regardless of immunization status, titers are required for measles, mumps, rubella, varicella and Hepatitis B. Measles and rubella immunity is required. Hepatitis B surface antigen is required only when Hepatitis B surface antibody is negative. Please note that laboratory results must be attached to the certificate of compliance health form.

7 (PLEASE PRINT LEGIBLY) LAST NAME FIRST NAME,M.I. DATE AFFILIATED INSTITUTION/CONTRACTING AGENCY CONTACT NAME PHONE NUMBER COOK COUNTY HEALTH & HOSPITALS SYSTEM CERTIFICATE OF COMPLIANCE Infection Control Policies All rotating physicians (including residents in affiliated programs, students, trainees, contracting agency employees and observers) who have contact with Cook County Health & Hospitals System (CCHHS) patients must adhere to the same infection control policies as apply to employees. These requirements follow CDC guidelines for infection control in health care personnel. Individuals continuing work at CCHHS must provide updated information on an annual basis. (See CCHHS Certificate of Compliance Annual Review Form) ALL PERTINENT LABORATORY RESULTS MUST BE ATTACHED TUBERCULOSIS: Tuberculin Skin Test (TST), 2 STEP on hire. TST reading must be done from hours after application. Individuals must have proof of 2 TSTs within 12 months prior to work for CCHHS, with the most recent TST completed during the previous 60 days. If there is a positive TST, a baseline Chest Xray is required. Quantiferon test results can be submitted for review. * If you participate in an Annual Infection Control screening program at another Institution, please see page 2. TST Date Placed Date Read /Result TST Date Placed Date Read/Result Step 1 Step 2 mm induration mm induration CXR (if required) Date: Result (ATTACHED): Quantiferon Test Date: Results Positive Negative If history of positive TST, individual must be evaluated by their health care provider concerning signs and symptoms of illness possibly related to tuberculosis, including unexplained fever, cough, weight loss and night sweats. For individuals with a previous documented history of positive TST, a baseline Chest Xray is required. The Chest Xray must have been performed within the past 6 months. Previous results may be accepted at the discretion of CCHHS EHS and Infection Control. Fever Yes No Weight Loss Yes No Cough Yes No Night Sweats Yes No SEROLOGY RESULTS ATTACH LABORATORY RESULTS MEASLES (RUBEOLA), MUMPS & RUBELLA Antibody titers indicating immunity to measles and rubella must be provided. It is advised that health care personnel have immunity to mumps MEASLES (RUBEOLA) IMMUNE NOT IMMUNE DATE: MUMPS IMMUNE NOT IMMUNE RUBELLA IMMUNE NOT IMMUNE DATE: DATE: HEPATITIS B IMMUNITY It is strongly advised by CDC and CCHHS that health care personnel have immunity to Hepatitis B. Hepatitis B Surface Antibody titers are required post immunization to prove immunity. If the Hepatitis B Surface Antibody titer is negative, Hepatitis B Surface Antigen is required. Date: HB Surface Antibody Positive Negative (RESULTS ATTACHED) Date: HB Surface Antigen Positive Negative (RESULTS ATTACHED) VARICELLA It is advised that health care personnel have immunity to Varicella. Date: Varicella IMMUNE NOT IMMUNE (RESULTS ATTACHED) Revised 05/25/10 Prepared by the Office of: Purple.Form John H. Stroger, Jr. Hospital of Cook County Employee Health Service/Infection Control Page 1 of 2 ANNUAL INFLUENZA VACCINATION

8 Annual Influenza Vaccination is mandatory. Annual Influenza Vaccine administered on-site for current flu season. Medical contraindication (documentation included). Annual Influenza Vaccination administered elsewhere (documentation included) Name of Trainee/Contractee: Telephone Number: (Print) Address: Street City/State Zip Code I understand the Infection Control requirements of the Cook County Health & Hospitals System. I have undergone the tests listed above and give my permission for the person named hereon to release these results to the Cook County Health & Hospitals System.. Signature of Trainee/Contractee CERTIFICATION OF RESULTS I certify that the information herein is complete and correct to the best of my knowledge. Date Signature of Health Provider, Title (MD,RN, other) Name of Institution or Agency** Phone Number Printed Name Address Date **OFFICIAL STAMP OR SEAL OF INSTITUTION OR AGENCY IS REQUIRED EXPLANATORY INFORMATION * If you participate in an Annual Infection Control Screening Program at another Institution, please forward the results with this form. We will review the information forwarded and inform you if further information is necessary. If your annual TB screening is up to date and you plan to continue Infection Control screening at the outside Institution, you do not need to have another TST from within the past 2 months unless there are additional indications. TUBERCULOSIS Two- step Tuberculin Skin Testing (TST) is required prior to work for CCHHS. Standard TST testing of 5TU intradermal is given. Individuals with two-step TST done in past, with continuous annual screening following the two-step TST, should provide documentation of this and continue annual screening. If positive (> 10 mm induration), a chest x-ray is obtained. If the initial TST is negative, a second 5 TU TST, performed at least one week after the first negative TST, is required. The TST results must be from within the past 12 months, with the recent TST from within the past 60 days. If either TST is positive, the individual must be assessed for the signs/symptoms of active tuberculosis and a chest Xray obtained. Individuals with a documented history of positive TST or active tuberculosis are not required to undergo TST testing. A baseline Chest Xray result from within the past 6 months must be forwarded with this Infection Control information. Tuberculosis screening must be updated annually for work at CCHHS. RUBELLA (German Measles) All individuals must have evidence of Rubella immunity documented by antibody titer prior to work at CCHHS. RUBEOLA (Measles) All individuals must have evidence of Measles immunity documented by antibody titer prior to work at CCHHS. MUMPS It is advised that all health care personnel have immunity to Mumps. In the event of an exposure, nonimmune individuals would be precluded from work and requested to receive mumps vaccine. HEPATITIS B Hepatitis B Surface antibody status is required. It is strongly recommended that all individuals participating in this program complete the immunization series for Hepatitis B. Once completed, immunization status must be CONFIRMED by repeating the Hepatitis B antibody titer test. If a blood or body fluid exposure occurs at work, individuals not immune to Hepatitis B would be offered Hepatitis B immunization and possibly advised to receive Hepatitis B immune globulin. VARICELLA Varicella IgG Antibody testing is required. It is strongly recommended that non-immune individuals be vaccinated. In the event of a varicella exposure, non-immune individuals would be precluded from work, advised to receive varicella vaccine and possibly be advised to receive Varicella Zoster Immune Globulin. TETANUS DOCUMENTATION NOT REQUIRED - Vaccination or booster within 10 years is recommended. Revised 05/25/10 Prepared by the Office of: Purple.Form John H. Stroger, Jr. Hospital of Cook County Employee Health Service/Infection Control Page 2 of 2

9 CRIMINAL BACKGROUND CHECK If your school does not routinely do a routine criminal background check (CBC) upon matriculation, you will be required to obtain one before you start your rotation at John H. Stroger Hospital. This is the law in Illinois, and no exceptions can be made. In an effort to make this as easy as possible, we have placed the names and contact information for all of the vendors in our area that work with the state to initiate CBC s. We post this information for your convenience only, and do not endorse any particular one. A Fingerprinting has offered to perform a CBC with the Illinois State Police for most individuals for $20, with a turn-around time of twenty-four hours. Again we do not endorse this vendor, and present their information as a convenience only. Requests for a CBC through this vendor can be made via fingerprintingchicago@gmail.com The basic Information needed: 1) Last Name 2) First Name 3) Middle Initial 4) Sex 5) Race 6) SSN (optional) ** and Phone number for contact information They can take payment over Visa/MasterCard over the phone (Mr. Shah at: )

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