Application for INTERNATIONAL SPECIAL ELECTIVE Consideration

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You must submit this application at least 12 weeks in advance of your elective
To assure a safe and valuable global learning experience for you, the International Elective approval process
involves collective input from various offices:
 the Host international institution
 the College of Medicine Office of Global Health Education
 College of Medicine Special Electives Committee
 Drexel Office of Study Abroad
As FIRST step, please meet with the Office of Global Health Education, to review the application process,
requirements, and considerations. We suggest starting this process at least 6-9 months of your desired travel.
THEN, submit this signed completed application to Ms. Marcine Townes at the Division of Clinical Education
( ), 2900 Queen Lane, Room 114K, Philadelphia, PA, 19129; Fax# 215-843-7738
And a copy of the following documentation:
 A cover letter from the student explaining the request and outlining the educational objectives the
student wishes to achieve from the rotation. This must be signed by the student.
 A description of the elective signed by the course director. This should include a weekly grid of activities.
 Letter from away school or site indicating acceptance for rotation and specifying dates signed by the away
 An Approval of the Pathway Director/advisor (specific form).
 A copy of the Student's 4 year schedule (please complete form) Do not provide printed schedule
 Signed DUCOM Statement of Responsibility and Legal Release must be included
Phone #:
Your Signature:
Pager #:
Nature of the elective and/or the place the elective will be completed. Check ALL that apply.
An international medical school site that sponsors an elective
An international non-medical school site that sponsors an elective
An international research experience.
Other (please explain)
Title of proposed elective
Discipline for your proposed elective
Name of your elective
Location of proposed elective (town,
providence, country)
Application for International Special Elective Consideration, 12.14.2014
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Dates of elective (inclusive:)
(must attend min of 4 wks)
Number of proposed weeks credit
Do you have relatives/friends at this
site? Is so, who and what is the relationship?
Contact information of host program
 telephone
 fax
 address
 email
Names of:
 Course director
 Faculty supervisor
 Administrative contact
Information about Course and Evaluation (may submit a letter w this information included)
Course Goals:
Course Objectives:
Are these objectives consistent with the length of your elective?
What will be the evaluation process? (clinical observation, oral presentation, history and
physical, progress notes, …?)
Who will supervise your work on a daily basis?
Who will give daily feedback?
Does s/he hold a faculty position? What discipline? What is his/her title? What specialty? If
not, what is their role?
Name AND discipline of physician who will write the final evaluation:
 Please note that students are to receive verbal feedback at midpoint and both verbal & written feedback at the
end of the rotation.
Application for International Special Elective Consideration, 12.14.2014
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 Evaluation: The Division of Clinical Education will provide each student with a personalized evaluation form to
take to the host international program. Upon return, the evaluation form may be faxed or scanned to the
Division of Clinical Education and the original form hand-carried or mailed.
Day To Day Details Of Your Elective:
Provide a grid of your daily and weekly schedule, including: patient care time, your hours, night
call, didactics, procedures (if yes, who will supervise), and setting (inpatient, outpatient, outside
If known, describe the patient population you will encounter:
Will you be writing orders? If so, is there supervision?
Are there other learners at site at the same time as you? Medical Students? Residents? Other
physician? Other health care workers? Please indicate who and how many?
If known, has the site had visiting medical students before? When? From Where?
Host Course Director name & signature
Pathway Director/Advisor name & signature
In lieu of the host signing this application, you may obtain their signed approval in a letter which includes detailed
contents of the elective.
Special Electives Committee action date: ____/____/____
Decision deferred
Other (specify)
Signature of chair :
Special Elective Application materials are due the 1st Friday of each month to be considered at the monthly Special
Elective Committee meeting which is held the 3rd Friday of the month. Applications received after the 1st Friday will
be reviewed the following month.
Decisions will be released the following week. Additional information may be requested following review. Allow at
least 8 weeks advance notice for Special Elective Applications.
Retroactive Credit will NOT be granted -- please submit requests in advance.
After approval from Special Electives Committee, there will be additional
requirements for approval of the International Experience to assure your health
and safety.
Application for International Special Elective Consideration, 12.14.2014