Rotating Students/Providers

• All required fields must be completed before submission.
• Please ensure your contact information is accurate.
• If you are an Oakland University William Beaumont School of Medicine Student Run Free Clinic (SRFC) student, you only need to complete this form once per calendar year.
  • For Rotation Start Date, enter: January 1 of the current year
  • For Rotation End Date, enter: December 31 of the current year
• If you are a licensed provider (e.g., Resident Physician, Fellow), you will be required to provide your NPI number.

All student learners and trainees must have current immunization/vaccination records and a completed TB risk assessment on file with their school or training program prior to participating in clinical activities. By completing this form, you will be asked to verify that your institution maintains these records. The clinic may request documentation if needed for compliance or audit purposes.