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

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?