Physician’s Statement (Mandatory)

– To be completed by physician

Your patient ______will shortly participate inForeign Medical Scientist Fellowship program at Samsung Medical Center (Seoul, South Korea). As he/she may be directly involved with patient care in the fellowship program, some information about health status and immunization history of him/her should beprovidedprior to his/her placement. Please complete this form and return it to Samsung Medical Center, which will facilitate administrative process.If you have any question, please contact Mr. Max Lee via email () or by phone (+82-2-3410-3094)

International Training Office (ITO)

Samsung Medical Center

50 Ilwon-Dong, Gangnam-Gu

Seoul, Korea, 135-710

  1. Personal Details

Title: ______

Family Name: ______First Name:______

Date of Birth: ______Nationality: ______

2. Medical History

Hashe/she ever been treated for Tuberculosis?( Yes , No )

If yes, please provide details about the dates of the treatment:

Start Date: ______End Date: ______

Does he/she have a verified scar of BCG vaccination? ( Yes , No )

Has he/she ever been treated for chicken pox?( Yes , No )

If he/she hasa history of any other communicable disease, please provide details:

Diagnosis: ______Recovery Date: ______

Diagnosis: ______Recovery Date: ______

3. Test Results (within three months of your visit to Samsung Medical Center)

1) Chest X-ray(required for all applicants)

Result: ______

Date: ______

2) Anti-HIV titer (required for applicant who will be involved with surgical procedure)

Result: ______

Date: ______

4. Immunization record

DISEASES / IMMUNIZATION DATES / Antibody Titer
TITERS
Date #1 / Date #2 / Date #3 / Date #4 / Date / Result
BCG
Hepatitis A
Hepatitis B
Adult Td*
MMR†
Varicella
Other

* particularly required for applicant who will be involved with animal experiment.

† particularly required forwomen applicantwho will be involved with pediatric patient care.

5. Overall Comments

1) Does this patient have communicable disease(s)? ( Yes No )

If yes, please provide details: Diagnosis: ______

2) Does this patient have any health condition(s) that may interfere with his/her ability to work as a healthcare professional? ( Yes No )

If yes, please provide details: Diagnosis: ______

I certify that all the information I have given on this form is complete, truthful, and accurate.

Date: ______

Physician’s Information:

Name/Title: ______Signature:______

Address(Hospital):______

Official(Hospital/Clinic) stamp: