Non-Global Health Residency Track Electives

Residents who are planning a global health elective and who are not part of the Global Health Residency Track (GHRT) program, should complete this application form. Residents should also apply for a Josephson Fund Grant (www.bhjfund.org)

Before submitting this form, ensure that you have:

Submitted the risk management form to the Global Health Center office in Annenberg 12-21.
Reviewed your health insurance policy and ensure that you have coverage for emergency services when out of the country.
Visited Employee Health at least 3 months prior to departure, determined whether you need any vaccines, and whether you should bring along HIV post-exposure prophylaxis.
Considered obtaining a global phone (not mandatory, but strongly encouraged).
Emailed global.health@mssm.edu to obtain evacuation insurance from International SOS. Provide your birthdate, location you are traveling to, and dates of travel in the body of the email, with "SOS" in the header.
Residents must submit a feedback form upon completion of their global health experience
Click here to access the post-trip evaluation form.

IF YOU ARE APPLYING FOR FUNDING through the Global Health Center, you must submit this elective form as well as complete the additional requirements on the pre-trip checklist.

Name: *

Residency Program and PG Year: *

Email: *

Life Number: *

DOB: *

Date of Birth

Address: *

Cell phone: *

Alternate phone number: *

Mount Sinai supervisor/mentor:

Are you working with a supervisor/mentor at Mount Sinai? Please provide his/her name, title, and department.

Emergency Contact name: *

Please provide us with an emergency contact in the US

Emergency contact phone number: *

Global phone number:

In-country mentor/contact name: *

In-country mentor contact email:

In-country mentor telephone number: *

I have confirmed that my insurance provides emergency health coverage in my destination country: *

yes

I have visited Student Health or my doctor to discuss vaccines and prophylactic medications: *

yes

I have submitted my request for SOS insurance: *

yes

Please email global.health@mssm.edu with the following; your name, DOB, dates of travel, and country that you are travelling to.

I have submitted the liability form to the GHC office: *

yes

country: *

city/region: *

Please provide the name of the city, or region (if you are travelling to a rural area)

dates: *

dates of your elective

organization: *

please provide the name of the organization with whom you are working.

Languages: *

Please list the languages which you speak and whether any of these will be used at the proposed elective site. If you do not speak the local language please describe what steps are in place to enable communication while you are at the site.

project proposal:

Please provide a 250 word abstract which describes the work you will be doing during your global health elective.

Motivation: *

Please describe your reasons for pursuing a global health elective and how this proposed elective will impact your overall future goals as a physician. (1000 words maximum)

Budget: *

Please provide an estimate of your costs for the elective, including travel and in-country costs (including tuition, if applicable). This will help other students who are considering doing this elective in the future, and will be taken into consideration for funding purposes.

Have you applied for the Josephson Fund Grant?: *

Yes

Have you applied for or received funding from other sources? If so, please list.: *

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Non-Global Health Residency Track Electives