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From Your GME Leaders
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Continuing Professional Education
Dahlgren Memorial Library
Foundations Curriculum
Academic Investment
Medstar GME Policy on Moonlighting
Your Voice
Shout Outs
GME Shout Outs
People Profiles
Nominate a Shout Out
From Your GME Leaders
Welcome
Academic Affairs Leadership
MedStar-Georgetown Partnership
GME Town Hall
GME Town Hall Q&A
Institutional Accreditation
Upcoming Events
Your Safety
Workplace Violence
Donning and Doffing
Safety in the Clinical Learning Environment
Patient Safety
Fatigue Mitigation
Enhanced Safety Screening Policy and Process
COVID-19 Policy
Your Wellbeing
Your Compensation and Benefits
MedStar Connects You
Your Wellbeing Resources
Working Group for Racial Justice
Specialty Respect
Your Education
Health Equity & Global Health
Residents as Teachers
Committee Opportunities
Continuing Professional Education
Dahlgren Memorial Library
Foundations Curriculum
Academic Investment
Medstar GME Policy on Moonlighting
Your Voice
Shout Outs
GME Shout Outs
People Profiles
Nominate a Shout Out
International Rotation Application
International Rotation Application
*
indicates required field
Are you a MedStar Global Health Equity Track Resident/Fellow?
Yes
No
Name
Email
Phone
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
Proposed travel dates
Identify the emergency evacuation/travel insurance you will purchase
Site of interest (name)
Direct clinical supervisor onsite
(i.e., who will complete your evaluation)
Site Address
Site Address Line 2
Site City
Site State / Province / Region
Site ZIP / Postal Code
Site Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
The Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Is language fluency required for this site?
Yes
No
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 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?
Submit