Global Health Residency Track Project Proposal Form

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Global Health Residency Track Project Proposal Form

Please submit the following application for your global health track senior elective project.

Name: *

Last name, first name

I have confirmed that my health insurance covers emergent medical care while I am away: *

yes

I have filled out my medical liability form for liability coverage while I am away:

yes

This is mandatory

I have obtained a phone with international calling capability:

yes

i have chosen not to get a phone

i am looking into getting a phone

You should strongly consider having a global phone for emergencies.Â We need to be able to reach you, and vice versa.

I have obtained SOS insurance: *

yes

This is required, and you must ensure that you have evacuation insurance.

I have visited my MD and obtained necessary vaccinations: *

yes

This is mandatory

Residency: *

Emergency Medicine

Internal Medicine

Pediatrics

Med-Peds

Psychiatry

ObGyn

Location of elective: *

Country, region, state, city

Name of on-site project faculty mentor with all contact information (phone, email):

Name of Sinai faculty mentor:

Name of Sinai faculty who is overseeing your project

Partner organization:

Name of NGO you are working with, or name of academic institution

Please describe your project: *

Please provide a detailed description of your project, including a background section, a methods section, which describes the research project or public health intervention which you are involved in, and highlights your role within the project. Finally, please add a goals section, which details what skills you plan on acquiring through participation in this project.

Budget: *

Please provide an estimation of your expenses, including flight and other travel costs, room and board, and other project-specific expenses.

Emergency Contact: *

Please provide the name, address and phone number of next of kin or family member who we should contact in case of emergency

In-country contact information: *

Please provide us several ways to get in touch with you, including global phone number, hotel/residence phone number, institution/NGO number, etc.