University of Colorado Anschutz Medical Campus

Global Health Elective Application Form

First Name

Last Name

M.I.

Current Address (Number and Street, City, State, and Zip)

Phone

Email

PGY Year

Track

Fill in the blank if you selected Fellowship (Which fellowship, year of fellowship)

Fill in the blank if you selected Faculty (Division, Rank)

Which country are you interested?

Describe or list prior educational and research experiences in the field of global health (include year, duration of experience, relevant coursework, conferences, degrees/certifications, and scholarly work produced)

List the three main educational benefits that you expect to receive from doing a global health elective rotation:

Speak local language

Philippines
Nepal
Other... This choice will expand a text box

What month of the upcoming academic year July 2018-July 2020 are you planning to take the Global Health elective? (Please provide in order of priority, as we will try to assign your top preference)

Do you have any personal or family restrictions that will preclude you from fulfilling your global health elective successfully?

If yes, please describe and discuss how you would anticipate to accommodate those restrictions into your rotation

Describe the reasons that you want to participate in this international elective as they relate to your overall career goals. How have your prior experiences prepared you for this experience? What do you hope to achieve by working on this elective?

I agree, acknowledge, and understand the Acknowledgement of Global Health Elective Conditions listed below

Yes
No

E-signature of the resident/fellow

Date

Acknowledgment of Global Health Elective conditions

A. I understand that in order to have a well prepared and successful Global Health Elective rotation I need to begin preparation of my paperwork and pre travel requirements as soon as I am notified by my program director that I have been selected for a rotation slot. Normally travel prep begins 3-6 months prior to travel. Contact Ali Musani email ali.musani@cuanschutz.edu

B. I understand that there are safety and health risks inherent with traveling to and working at the Hospital and the clinic.

C. I agree that I will not take personal vacation during the month that I have selected to do my Global Health elective rotation

D. If I am selected for one of my chosen months to do the Global Health elective rotation, I will ensure that I fulfill that obligation in order to provide the continuity of care for the underserved populations at that site, unless there is an exceptional reason (severe illness, death, or a serious impediment) that precludes me from doing the rotation. If I need to reschedule my rotation I will contact my Global Health liaison of the program and Dr. Ali Musani.

NOTE: Please send your CV to Ali Musani, ali.musani@cuanschutz.edu after clicking on the submit button.

Department of Medicine (SOM)

CU Anschutz

Academic Office One

12631 East 17th Avenue

8601

Aurora, CO 80045

303-724-1785

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Global Health Elective Application Form

Acknowledgment of Global Health Elective conditions

Department of Medicine (SOM)