Paul S. Lietman Global Health Travel Fellowship for Residents and Fellows Application and Commitment Form

Paul S Lietman Global Health Travel Fellowship for Residents and Fellows Application and Commitment Form - Spring 2020 – (This form must be accompanied by a completed “Request for Elective Rotation” form with required attachments GHPP Students must complete all *asterisked items*) Part - Background Information 1.1 Identifying Information Applicant Name Last:       First:       Middle:       Citizenship Citizenship: Select Citizenship VISA Type:       Local Address Street:       City: Contact Information If “Other” please specify             State:       Zip:       Email:       Phone:       1.2 Rotation Related Information Training Program Department       Status Resident JHH Fellow JHBMC Other, spec       Other, spec       NPI       Employee Number       (associated with your payroll, not your JHED or badge ID) Rotation Dates (approx.) From:       To:       Rotation Location Number of weeks:       City:       Country:       Is this country considered a low- or middle-income country by the World Bank?       Global Health Pathways Are you in the Global Health Pathways Program?       Program* If you are applying through the GHPP, please indicate your track: Select Track Supervision Information and Faculty Mentor: (who will be submitting your letter of recommendation) Name and Title of Hopkins Elective Mentor and Supervisor:      Email:       Name of In-country Supervisor:       Email:       1.2 Please list any relevant publications and honors: Lietman Travel Fellowship Page of Email questions to Lillian James | lietmanfellow@jhu.edu       1.3 Previous overseas travel to developing countries for reasons other than vacation/tourism Country Reason for travel Year Total Time                                                                         Part - Personal Statements 2.1 Career goals Please describe your short (post training) and long-term (5-10 years out) career goals/plans (Maximum of 250 words)       2.2 Elective Description Please provide a description of your planned elective activities and the clinical/research setting (Maximum of 200 words)       2.3 Training goals Please describe what you will be doing during your elective how you believe will help you achieve your training goals Provide 2-5 training goals for your elective rotation ie What new knowledge and skills you seek to acquire from this experience? This must be narrative – not copy your general ACGME training goals (Maximum of 250 words) Lietman Travel Fellowship Page of Email questions to Lillian James | lietmanfellow@jhu.edu       Part – Funding Budget Please identify the funding you will need to conduct the fellowship in your selected location Note: Paul S Lietman Global Travel Fellowships are capped at $5,000 Please note: 1) the sum of expenses in large categories should total the amount you are requesting; expenses beyond $5,000 should not be included; 2) Use lines marked “Other” to present other required expenses, enter category in left column; 3) cite your source for estimating the amount; 4) enter expenses in USD Budgets submitted indicate to reviewers the expected expenses but not influence decisions regarding award amount The primary consideration for award amount is duration of rotation Typically, awardees in country for weeks or less receive $3,500, 5-6 weeks can receive $4,000 and 6+ weeks are eligible to receive the maximum of $5,000, though these numbers are subject to change and are not guaranteed Item Source of Estimate Amount Transportation             Housing             Food             Other             Other             Total Request       Part - Other Funding Have you submitted an application for funding of this rotation from additional sources other than the Center for Global Health? No Yes If you have selected YES, please list and describe all Source of Funding Amount Requested Status (Select)             (SelectOne)             (SelectOne)             (SelectOne) Lietman Travel Fellowship Page of Email questions to Lillian James | lietmanfellow@jhu.edu Part - Commitments Applicant: 5.1 Applicant agrees that if selected for this placement s/he will complete the reporting requirements listed above within one month of his/her return from the elective including a debrief with CGH Yes No 5.2 If performing clinical care, applicant agrees that s/he will care for patients under the direct supervision of a local preceptor, within the limitations established by my level of training Where feasible, the applicant agrees s/he will give all patients a choice of whether or not to have trainees involved in their care Yes No 5.3 Applicant agrees that if selected for this placement s/he will present if possible on her/his experience at the next Global Health Day following the completion of their rotation provided that they are still in training at Hopkins Yes No 5.4 Applicant certifies that if selected for this placement he/she will prepare as completely as possible including learning about endemic diseases, all appropriate vaccinations and prophylaxis recommended by the JHU travel clinic, local health care issues, laws, standards of care, and customs Applicant certifies that he/she understand that the same standards of professionalism apply when rotating abroad as Johns Hopkins university, including full disclosure about my status as a trainee, discussing patient care with a supervising preceptor, and obtaining consent in an ethically and culturally appropriate manor Yes No Yes No *GHPP applicant certifies to complete all Global Health Pathways Program specific requirements, in addition to CGH requirements A response is only required for GHPP participants Yes No 5.5 5.6 APPLICANT SIGNATURE:       Signature of Application Lietman Travel Fellowship       Date (mm/dd/yyyy) Page of Email questions to Lillian James | lietmanfellow@jhu.edu Application Instructions: • Complete and save this application • Print and sign this application form • Download (see web page), complete, and save the “Request for Elective Rotation” form as an electronic file; print the “Request for Elective Rotation” with all the required attachments Have your residency director sign the RER form • Obtain one recommendation from your mentor or other faculty member at Hopkins (see form) The letter of recommendation form (LOR) should not come from the applicant • Please send: o Electronic, signed copy of the completed “Housestaff Travel Grant Application Form” and completed “Request for Elective Rotation” in MS Word o Separate Word file with your rotation objectives as outlined in the “Request for Elective” – it is strongly recommended applicants describe how their proposed elective will help achieve their training goals o Your recommender must upload an electronic version of the LOR to recommendation form • Save forms in the following format—last name, first name_title of form (ex Doe, Jane_app) • GHPP applicants are also required to submit approval from the Osler Medical Residency (S Desai or N Aggarwal) and an email to the GHPP Director, Yuka Manabe (ymanabe@jhmi.edu) from: o Track 1: the country director (see webpage) o Track 2: the research supervisor Upload all application materials by 11:59 p.m EST, April 9, 2020 Lietman Travel Fellowship Page of Email questions to Lillian James | lietmanfellow@jhu.edu ... lietmanfellow@jhu.edu Application Instructions: • Complete and save this application • Print and sign this application form • Download (see web page), complete, and save the “Request for Elective Rotation” form. .. recommendation form (LOR) should not come from the applicant • Please send: o Electronic, signed copy of the completed “Housestaff Travel Grant Application Form? ?? and completed “Request for Elective... must upload an electronic version of the LOR to recommendation form • Save forms in the following format—last name, first name_title of form (ex Doe, Jane_app) • GHPP applicants are also required