Questionnaire for Fairview Retirement Plan Purposes Question Title * 1. To ensure we are applying your responses accurately to your record we require that you fill out the following information. Employment Start Date Last Name First Name Fairview Employee ID (if known) Last four digits of Social Security Number Preferred Contact Phone Number: Question Title * 2. Have you ever worked for Fairview Health Services or one of our affiliates? Yes (If yes, select and go to question 3) No (If no, select and go to question 5) If you selected yes please provide dates or time frame of prior employment period(s). Question Title * 3. Please select those Fairview facilities and/or Fairview-affilliate facilities for whom you may have previously worked prior to the hire date of your current position. If you have not previously worked for Fairview or one of our affilliates please select None. None Arden Hills Family Physicians Bloomington-Lake Clinics (Past service credited for employees who transferred to Fairview with merger on 11/15/2011) BRIM and Associates Cedar Ridge Medical Center Chisago Health Services Columbia Park Medical Group (Past service credited for employees who transferred to Fairview with merger on 1/1/2008) Diamond Lake Medical Clinic (formerly Southwest Internists) District Memorial Hospital Downtown Internal Medicine Eagan Medical (1988 to present) Ebenezer Society Eden Center Family Physicians F & T Medical Clinic (10/91 to 10/92) Fairview Corporate Offices Fairview Foundation Fairview Home Care & Hospice Fairview Lakes Hospital Fairview Medical Group (Fairview Clinics) Fairview Northland Clinics (Rum River Medical Associates until 1996) Fairview Northland Regional Hospital Fairview Princeton/Milaca Hospital Fairview Range/Hibbing Fairview Ridges Hospital Fairview Riverside Medical Center Fairview Southdale Family Medical Clinics (1987 to present) Grand Itasca Clinic & Hospital HealthEast (6/1/2017 to present) HealthWorks (1987 to present) Hospital Home Care Indianhead Medical Center (Shell Lake) Institute for Athletic Medicine Iowa Lutheran Hospital Jonathon Clinic Lagoon Family Health Care Lutheran/Fairview Deaconess Maple Grove Surgery (Past service credited for employees who transferred to Fairview with merger on 3/1/2009) Minnesota Spine Center MN Heart (Past service credited for employees who transferred to Fairview with merger on 10/1/2008) Oxboro Clinics (1985 to present) Preferred One Professional OB/GYN Retail Pharmacy Ridge Valley Family Physicians Riverside Family Physicians (Past service credited for employees who transferred to Fairview with merger on 12/1/2010) Riverside OB/GYN SCPA (Past service credited for employees who transferred to Fairview with merger on 10/1/2008) Soteria (Past service credited for employees who transferred to Fairview with merger on 4/18/2007) Southwest Medical Spine Care St. Anthony Falls (now part of FMC) St. Mary's Hospital Staub Pediatric Clinic University of Minnesota Hospital 1997 and forward Vibrant Health Clinics (6/1/2019 to present) Waseca Area Memorial Hospital WestRidge Medical Clinic Question Title * 4. If you previously worked for Fairview or for a Fairview-affiliated employer did you participate in a Fairview retirement plan during your employment? Yes No I don't know Question Title * 5. Are you are registered nurse? Yes No Submit