Global Health Clinical Electives Application

International electives are available to fourth year medical students who are in good academic standing. Third year students may receive permission on a case by case basis, and should discuss their elective plans with the Student Affairs office and Mount Sinai Global Health prior to proceeding. In order to receive one week’s credit, you must spend at least 40 hours during the week on this educational experience. You may not be under the direct supervision of any family members or individuals with whom you have a personal relationship.

Before submitting this application form, ensure that you complete the following pre-trip checklist:

  • Visit the CDC travel website several months prior to departure to determine whether you need any vaccines.
  • Please click here for Pre Travel Health Care Instructions for Students.
  • Confirm that your health insurance covers emergency medical care in the country you’ll be working and/or visiting.
  • Review the State Department website to determine if there are any travel warnings for the country you plan to visit.
  • Confirm that your passport is up to date. If your passport is expired or will expire within 6 months of your arrival in-country, renew immediately.
  • Determine if you need a visa to visit the country
  • Complete all required pre-trip requirements.

 

Your Name (required)

Date (required)

Class of (required)

Life Number (required)

MSSM Email Address (required)

Preferred Email Address (required)

Phone Number (required)

Dates of elective (required)

Please list the start and end dates of your elective

Country of Elective (required)

City or Region (required)

Type of Elective : Please check all that apply
 Clinical Experience Observation Research Patient Education Public Health

Elective Title (required)

Name of organization (required)

Please provide the name of the organization(s) with whom you are working. Also provide the name of any medical schools or medical centers where you will be working

Goals/Objectives of the Elective (list at least 3) (required)

Description of Elective (required)

In one page or less, describe your elective including its main focus, setting, supervision, patient contact (if applicable), and student responsibilities. Please include details regarding the manner in which this elective will be an active learning experience (e.g. participation in case conferences, presentation of patients to preceptor)

Hours per week (required)

Total Weeks (required)

40 hours are required for 1 week of credit

Languages (required)

What is the primary language requirement for your elective?

To what level of proficiency will you be expected to communicate in that language?
 Beginner Intermediate Advanced Fluent N/A

Mount Sinai mentor/contact name (required)

Mount Sinai mentor/contact email address (required)

Mount Sinai telephone number (required)

In-country mentor/contact name (required)

In-country mentor/contact email address (required)

In-country mentor/contact telephone number (required)

Please attach a formal letter from your on-site mentor/supervisor (required)

In this letter, your on-site mentor/supervisor should confirm his/her approval and agreement to the following policies: 1) students must spend at least 40 hours per week under supervision in order to receive one week of credit, and 2) supervisors must submit an evaluation of the student's work at the completion of the elective experience

Please rate your interest in participating in a global health clinical elective 1 to 5 (1=not at all important to me, 5=most important to me)

Learning clinical skills (required)
 Not at all important to me Somewhat important Neither important, nor unimportant Important  Most important to me

Seeing diverse pathology (required)
 Not at all important to me Somewhat important  Neither important, nor unimportant Important Most important to me

Conducting public health research (required)
 Not at all important to me Somewhat important Neither important, nor unimportant Important Most important to me

Conducting clinical research (required)
 Not at all important to me Somewhat important Neither important, nor unimportant Important Most important to me

Please rate your motivation for participating in a global health clinical elective 1 to 5 (1=not at all important to me, 5=most important to me)

Helping underserved populations (required)
 Not at all important to me Somewhat important Neither important, nor unimportant Important Most important to me

Acquiring language skills (required)
 Not at all important to me Somewhat important Neither important, nor unimportant Important Most important to me

For personal growth (required)
 Not at all important to me Somewhat important Neither important, nor unimportant Important Most important to me

Budget (required)

Please provide an estimate of your costs for the elective, including transportation, accommodation, meals, & project-related costs

What is the estimated total cost of your elective? (required)

Other sources of funding (or state NONE if you do not have other sources (required)

Funding is only available for electives that are at least 4 weeks in duration.

Are you applying for a Mount Sinai Global Health Center Scholarship? (required)
 Yes No

How did you identify this global health elective opportunity?(required)

(Website, faculty member, personal contact, another student, other)? Please be specific. This information will be very useful for future students

Please upload your CV

Post-trip Requirements

  • Submit your evaluation/grade form to Kamila Bryson (kamila.bryson@mssm.edu) in Annenberg 13-30. This step is mandatory in order to receive elective credit
  • Complete a feedback form that is submitted on the GHC website.
  • Submit any key photos/video from your elective experience to the GHC. Email these photos to: mssmglobalhealthcenter@gmail.com.

Global Health Faculty Signature (For Internal Use Only)

 
Mount Sinai Global Health Training
Community•Partnership•Transformation
Mission
Training healthcare workers in the U.S. and abroad to tackle the health problems of the world’s neglected and under served populations.