OU-HCOM -- Supplemental Application

Ohio University Health Science Center
Supplemental Application for Global Health Rotation, Research Placement or Internship

Please complete this application as well as the EAIS application (through the Office of Education Abroad) at least four months prior to your planned rotation. Follow the Checklist for Independent International Rotations to ensure that you complete the other necessary paperwork for your rotation to be approved.

Completion of this application helps us determine the quality and safety of the proposed global health experience. You may want to review the Guidelines for Ethical Practice for International Rotations and the Pre-Departure Packet before completing the application. Please provide thoughtful and complete answers. Proposals with insufficient information will not be approved.

In order to get credit for the rotation, you must complete all requirements listed in “Requirements for Global Health Rotation, Research Placement or Internship."

Name:

Dates:

Location:

1. What type of rotation are you proposing? Clinical Research

2. Briefly describe the setting(s) in which this will take place. (Include a description/nature of the location and staff, and level of supervision to be provided by your preceptor or other medical staff.)

3. What ethical situations might you experience during this rotation? How do you plan to address these situations?

4. What do you seek to gain from the proposed elective? Please list at least four educational goals from this experience.
(For example: to expand my knowledge of infectious disease or to increase understanding of epidemiological research.)

5. Describe how the proposed rotation will enable you to reach these goals. (If participating in a research rotation, attach research proposal and IRB approval letter).

6. Describe how you intend to prepare for this rotation (e.g. prior seminars, readings or GHEC Modules related to your educational goals).

7. Where do you propose to stay during the rotation?

8. What are potential safety concerns in this region (as noted on the U.S. State Department's international travel page - www.travel.state.gov) and how do you propose to take precautions?

9. What type of visa do you need to obtain prior to entering the country and when do you intend on getting it?

10. According to CDC recommendations (http://www.cdc.gov/travel/), what immunizations must you get prior to arriving in the country and what other measures to do need to take to ensure that you remain in good health during the rotation? When do you plan on getting these immunizations?

Ohio University
Heritage College of Osteopathic Medicine
Grosvenor Hall, Athens, Ohio 45701
Tel: 740-593-2183 FAX: 740-593-9557

Last updated: 01/17/2013