JOHNS HOPKINS FRAMEWORKS IN GLOBAL HEALTH



-135255-374015Global Health Leadership Program00Global Health Leadership ProgramGlobal Health Leadership Program Clinical Rotation Application and Commitment FormEligibility and Selection ProcessFor rotation in Q3 and Q4: 3rd and 4th year medical students that have/ will have completed the following core clerkships (by the desired rotation dates) are eligible to participate: Internal Medicine and either General Surgery or OBGYN. Preference will be given to 4th year medical students.For rotation in Summer, Q1 and Q2: 2rd and 3th year medical students that have/ will have completed the following core clerkships (by the desired rotation dates) are eligible to participate: Internal Medicine and either General Surgery or OBGYN. Preference will be given to 3rd year medical students.Selection will be based on personal qualities, academic and extracurricular records, demonstration of strong interpersonal and organizational skills, a well-developed sense of ethics, and a demonstrated interest or commitment to global health and reducing healthcare disparities.Please note that all students wishing to rotate in Lima, Peru must be proficient in Spanish. Deadlines and Rotation DatesCandidates for Q3 and Q4 must apply by 11:59 PM, the Sunday following the Q1 TIME course.Candidates for Summer, Q1 and Q2 must apply by 11:59 PM, the last Sunday of Spring Break.Please list ALL the potential dates during which you are available for the rotation. Part 1 - Background InformationIdentifying InformationApplicantLast: FORMTEXT ????? First: FORMTEXT ????? MI: FORMTEXT ????? JHED FORMTEXT ????? ISIS ID FORMTEXT ?????Date of Birth: FORMTEXT ?????CitizenshipCitizenship: FORMDROPDOWN If “Other” please specify FORMTEXT ????? VISA Type: FORMTEXT ?????Passport Number: FORMTEXT ????? Expiration Date: FORMTEXT ?????Local AddressStreet: FORMTEXT ?????City: FORMTEXT ????? State: FORMTEXT ????? Zip: FORMTEXT ?????Contact InformationEmail: FORMTEXT ????? Phone: FORMTEXT ?????Academic StatusSchool: FORMDROPDOWN Department: FORMTEXT ?????Area of Concentration: FORMTEXT ?????Expected Graduation Date: FORMTEXT ????? Clinical Site InformationSite LocationSelect First Choice Site: FORMDROPDOWN Select First Choice Site: FORMDROPDOWN Select First Choice Site: FORMDROPDOWN Rotation Rotation Dates: FORMDROPDOWN Secondary Dates: : FORMDROPDOWN Rotation of Interest: FORMTEXT ????? Medical Areas of Interest: FORMTEXT ?????Please list any relevant publications and honors FORMTEXT ?????1.4 Please provide your language skillsPlease list below your language skills. If you only speak English please select the “English Only” button. If you have skills in languages in addition to English please list each language and your level of proficiency in both conversation and reading/writing. FORMCHECKBOX ENGLISH ONLYProficiencyLanguageSpeech/ConversationReading Writing FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN FORMTEXT ????? FORMDROPDOWN FORMDROPDOWN 1.5 Have you ever lived and/or worked in a developing country? FORMCHECKBOX No FORMCHECKBOX Yes (please describe) FORMTEXT ?????1.6 Personal Statements1.6.1 Please describe your interest and future goals in global health (maximum of 250 words) FORMTEXT ?????1.6.2 Please describe any past activities in global health research or practice (maximum of 250 words) FORMTEXT ?????1.6.3 Why do you wish to complete this elective and what would you hope to gain from participating? FORMTEXT ?????1.6.4 What quality improvement project ideas do you have with your current knowledge of the clinical setting? (Naturally these are just brainstorms, considering you have yet to visit the setting.) FORMTEXT ?????Part 2 - CommitmentApplicant: Applicant agrees that IF s/he is selected for this elective and IF s/he accepts the acceptance, s/he will complete the full term of the elective at the international site (at least 4 weeks) except in extenuating circumstances. FORMCHECKBOX Yes FORMCHECKBOX NoApplicant agrees that IF selected for this elective, s/he will complete ALL mandatory predeparture training before travel to the elective site. The predeparture training is a combination of online and in person sessions on the following topics: FORMCHECKBOX Yes FORMCHECKBOX NoOverview of online institution resources and requirements for abroad electives including travel clinic, insurance topics, ISOSOnline case series in the Berman Institute of Bioethics Ethical Challenges in Short-Term Global Health TrainingIn person sessions (the exact sessions may change): Leadership; Health Systems; Research/ Quality Improvement; Informatics; Logistics Applicant agrees that if selected s/he will develop and complete (or at least have feasible plan of completion) a scholarly project. FORMCHECKBOX Yes FORMCHECKBOX NoApplicant agrees that if selected s/he will participate in the postdeparture debriefing, which is an in person meeting after the rotation at the clinical elective site to share experiences, present project findings, and discuss any issues. FORMCHECKBOX Yes FORMCHECKBOX NoApplicant agrees that if selected for this elective all appropriate vaccinations and other health requirements will be completed before departure to the field. FORMCHECKBOX Yes FORMCHECKBOX NoApplicant agrees to conduct oneself with the highest integrity, to uphold the reputation of Johns Hopkins University, and to be mindful of personal health and safety. FORMCHECKBOX Yes FORMCHECKBOX NoAPPLICANT SIGNATURE: FORMTEXT ????? FORMTEXT ?????_______________Signature of ApplicantDate (mm/dd/yyyy)Application Instructions:Please direct ALL questions to Dr. Chen cchen127@jhmi.edu. Please complete and save this signed application as an electronic file.Please obtain one letter of recommendation from a faculty member using the GHLP recommendation form. The faculty should submit the letter of recommendation directly to jhu.ghlp@ with the subject GHLP LOR “student name”.Please obtain and submit a copy of your unofficial transcript and scanned copy of passport.Please submit your curriculum vitae (please highlight relevant experiences/accomplishments).Please submit all forms to jhu.ghlp@. ................
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