Approval Form for Unaffiliated Global Health Sites
The Center for Global Health’s (CGH) travel policy for Feinberg students participating in clinical away-rotations and medical education programs at international sites may be reviewed by visiting the link below. All clinical rotations and medical education programs at international sites will be assessed using the criteria and standards set forth in this policy:
FSM students are encouraged to identify and propose new institutions for global health experiences at international sites as long as they meet the criteria set forth in FSM’s Center for Global Health travel policy. The approval form for unaffiliated global health sites and any supplemental information should be submitted to the Center for Global Health where it will be reviewed by a committee of medical school faculty and administrators. Approval is required prior to applying for FSM funding and/or elective credit for the global health experience. Please note that FSM’s policy states that the Center for Global Health committee reviews the international site only, while clerkship directors review the credit-worthiness of elective rotations. Students should be prepared to submit additional materials to a clerkship director if they wish to receive elective credit.
Complete the checklist below and submit all documents to the Center for Global Health no later than 60 days prior to your proposed travel date:☐ CV of Preceptor / Clinical Director
☐ Research and appropriate documentation on standards and laws set forth by local, state, and/or national regulations that apply to licensure and/or insurance requirements for visiting medical students.
☐ Contingency plan on emergency and other required medical services in local community
YES ☐NO☐ Does host-institution have a Post-exposure Prophylaxis kit available for international medical trainees in case of a needle-stick or other exposure to bloodborne pathogens?
☐ Statement of purpose that addresses the services offered by the host institution, what your role will be, and how you will contribute in the clinical setting or to the project on which you will work.
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Email: / Click here to enter text. /
NU ID Number: / Click here to enter text. /
Host Institution: / Click here to enter text. /
Location: / Click here to enter text. /
Proposed Start Date: / Click here to enter text. /
Proposed End Date: / Click here to enter text. /
Step 1: Request and submit the CV of the attending physician or other qualified medical personnel from the host institution who will be responsible for supervising and evaluating your work. It is the responsibility of the visiting medical student to acquire the CV and submit it to the Center for Global Health. It is not required that the CV be written in English, although this is preferred.
Step 2: Visiting FSM students who will be placed in a clinical setting should perform proper due diligence on the standards and laws set forth by local, state, and/or national regulations that apply to licensure and/or insurance requirements for visiting medical students. It is recommended that students contact the clinical director or attending physician at the host institution to inquire whether visiting medical students and/or visiting attending physicians (if applicable) are required to register with the ministry of health or if there are any other licensure or insurance requirements set by local, state, or national laws or regulations. Please provide the clerkship director or attending physician’s name, title, and email to CGH in addition to your findings regarding local regulations.
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Step 3: FSM students should prepare and submit a contingency plan on emergency and other medical services available in local community. This criterion is easily met for students participating in clinical rotations at a large or moderate-sized teaching hospital affiliated with an accredited medical school. Students who plan on visiting rural settings or international nonprofit organizations that do not work with local hospitals should map out a contingency plan for emergency and other required medical services. The nearest inpatient medical hospital with good quality emergency medical services as well as a transportation route should be identified. It is recommended that students consult International SOS services and HTH insurance for recommendations on local hospitals and available health care services. Students who have special medical needs and/or disabilities should plan accordingly to meet those needs and identify proper medical resources in the local community prior to travel. Submit the contingency plan to CGH using the space below.
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Step 4: Describe the relevant services offered by the host institution and please describe in detail the clinical work, medical education program, and/or public health project in which you will participate. What will be your role at the host institution? Lastly, describe the professional development opportunities that will be available to you in this rotation/program and how it will relate to your career objectives. Please respond in 300 words.
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