Global Health Rotation Application

Health Equity & Global Health, MedStar Academic Affairs

Global Health Rotation Application

"*" indicates required fields

Name*

First Last

Residency or Fellowship Program (i.e., Franklin Square Family Medicine):*

Program Director:*

Department Global Health Faculty Contact (if applicable):

Department Program Coordinator who will assist in PLA coordination and tracking travel information (flight, lodging address, in-country contact number, and emergency evacuation policy etc.):*

PGY Year:*

Site of interest (name and address):*

Proposed travel dates:*

Direct clinical supervisor onsite (i.e., who will complete your evaluation):*

Contact Information for onsite supervisor (email, phone, address):*

Email:*

Phone::*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is language fluency required for this site?*

Yes

If so, what is your current fluency level?

Please describe your accommodations and in-country travel arrangements (how will you travel from the airport to the site?):*

Please describe Travel Advisory Level and safety precautions you will take for this region:*

Travel Advisory Level Website

Please describe country specific Visa requirements for your travel (please note these may be based on nationality):*

Please identify country specific vaccination requirements (if any):*

Please identify the emergency evacuation/travel insurance you will purchase:*

(To be purchased through AXA Assistance USA, HTH Worldwide, or Seven Cornerswith a minimum of $250,000 coverage, average cost ~$100)

Please explain your role during this elective experience. If your role is clinical, please delineate day to day activities and frequency of direct clinical supervision. Please note that scope of practice should not exceed that of training in the United States.*

If role is clinical, will you be able to provide proof of governmental approval to provide clinical care? Please note that Observerships do not require this level of documentation.*

What are your goals and objectives for this elective rotation?*

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