Medical Student Rotation Application

The Medical Student Rotation Program teaches students/ residents essential clinical and practical skills.  Participating students rotate with Peconic Bay Medical Center and participating siteÕs faculty and residents in a variety of areas.   
 
Application Process 
A completed rotation packet must be sent to Kimberly Ranagan.  Please indicate on the application the preferred dates of rotation.  Our rotations are four (4) weeks in length.   
 
All required documents must be sent to the Kimberly Ranagan AFTER your rotation request has been confirmed. 
 
 Send PDF rotation packet, supporting documentation, and picture ID to: 
kranagan@northwell.edu  
 
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. 
 
Certificate of Malpractice Insurance 
Most medical schools will provide a certificate of insurance. If your school does not provide malpractice insurance for you on ÒawayÓ rotations, be sure to provide proof of insurance. You will not be approved without documentation that you have malpractice insurance coverage for your rotation.  
 
Health Requirements 
The Office of Medical Education requires medical students to provide proof of the following immunizations:  
¥ Proof of Varicella Rubella, Rubella immunity (serology) 

¥ Proof of Hepatitis B immunity (serology)  

¥ Annual Tuberculosis Screening  

¥ Annual Flu vaccine (during flu season) 

¥ Proof of T-Dap (within 10 years) 

¥ Proof of COVID-19 Vaccine 


All students must provide health documentation in order to begin a scheduled rotation.  
 
Letter of Good Standing 
Please have your school forward a letter of good academic standing and approval of the rotation for credit. An evaluation of your performance on the rotation will be forwarded to your school/ program upon completion of the rotation. 
 
Cancellation Policy 
Once your assignment has been confirmed, either by phone and/or mail, you are expected to complete the rotation. While cancellation may be necessary, please do so at least 60 days in advance.  
 
Parking 
On the first day of your rotation please park in the visitorÕs 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. 
 
 

Rotations Offered:    *Circle rotation being completed* 
- Family Medicine (Audition or Sub-I/Elective) o (If you are interested in our Family Medicine Residency, please indicate this is an ÒauditionÓ rotationÓ 




- Internal Medicine 

- Critical Care/ ICU 

- Infectious Disease 

- General Surgery (Sub-I/ Elective)


 
 
Trainee Information:  
*Please Circle Below* 
 
 
Name            Gender:  . Female . Male     . Other 
 
Address                
 
City            State        Zip    
 
Home Phone        Cell Phone       Cell Carrier     
 
Email Address (preferred)        or        
 
Emergency Contact Name:      ______ Relationship: ________________________ 
 
Phone:      
 
 
Rotation Selection 
Name of Rotation/ Department:________________________________________________________________ 
 
Rotation Dates: _____________________________________________________________________________  
 
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?__________________________________________________________________________________ 
 
School/Program Information 
School/ Affiliated Institution: __________________________________________________________________ 
 
Address:____________________________________________________________________________________________________________________________________________________  
 
City _____________________________________________State _____________________   Zip ___________ 
 
School Placement Coordinator: ____________________________________________________________    
Phone______________________________ Email Address _______________________________________   
Year in School (During Rotation):  __________________Anticipated Graduation Date: ___________________ 
 
Planned Specialty: ___________________________________________________________________________ 
 
 

 
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- DriverÕs License or Passport 
. Computer Access Forms 
. HIPAA Acknowledgement Form  
. Health Information- Immunizations Including: 
¥ Proof of Varicella Rubella, Rubella immunity  

¥ Proof of Hepatitis B immunity 

¥ Annual Tuberculosis Screening  

¥ Annual Flu vaccine (during flu season) 

¥ T-Dap 

¥ COVID-19 Vaccine 


. Surgery ONLY 
¥ ilearn scrub modules