Non-GHRT Resident Elective

Non-Global Health Residency Track (GHRT) Residents who are planning a global health elective, should complete the following form. Residents should also apply for a Josephson Fund Grant (www.bhjfund.org)

In addition, residents should contact the appropriate advisor to discuss elective plans:

Internal Medicine/MedPeds - Jonathan Ripp (jonathan.ripp@mssm.edu)
Pediatrics - Anu Anandaraja (natasha.anandaraja@mssm.edu)
Emergency Medicine - Sigrid Hahn (sigrid.hahn@mssm.edu)
Psychiatry - Craig Katz (craig.katz@mssm.edu)
Ob/Gyn - Taraneh Shirazian (taraneh.shirazian@mssm.edu)

Before submitting this form, ensure that you have:

Submitted the risk management form to Global Health office Annenberg 13-30. Click here to download the form.
Reviewed your health insurance policy and ensure that you have coverage for emergency services when out of the country.
Visited 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.

IF YOU ARE APPLYING FOR FUNDING through the Global Health Center, you must submit this elective form.

Name: *

Residency Program and PG Year: *

Email: *

Life Number: *

Emergency Contact name: *

Please provide us with an emergency contact in the US

Emergency contact phone number: *

Alternate phone number:

global phone number:

In-country mentor/contact name: *

In-country mentor contact email:

In-country mentor telephone number: *

Mount Sinai supervisor:

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

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

yes

I have submitted letter of approval from in-country mentor to the GH office (global.health@mssm.edu): *

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 risk managament: *

yes

see top for link to the liability form.

city/region: *

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

country: *

dates: *

dates of your elective

organization: *

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

clinical responsibilities during elective: *

research proposal:

budget: *

Please provde an estimate of your costs for the elective, including travel and in-country costs (including tuition, if applicable).

Are you applying for elective funding though the Mount Sinai Global Health Center?: *

yes

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Non-GHRT Resident Elective