Yale School of Medicine, Department of Medicine, Office of Global Health
Independent Site Request Form for YNHH Residents in Internal Medicine
Instructions: Please return this completed form and the Office of Graduate Medical Education’s Application for a NonStandard Off-Site Elective Rotation to Laura Crawford (LMP 1094A). Please note that the Department of Medicine’s
Office of Global Health is interested in rotations in a low technology setting where you will be dependent upon your
physical diagnosis skills and where you will be helpful to the staff and not merely an observer.
You will also need a letter from your sponsor at the host institution on letterhead describing
 The hospital
 Your responsibilities (including the portion of time in outpatient versus inpatient settings)
 Whether the hospital has hosted Yale residents, and when, and
 If this is a short or long-term collaboration with Yale.
The letter of support from the host institution may be mailed or emailed as an attachment. Please let your sponsor know
to send it to: Laura Crawford; Office of Global Health, Department of Medicine, Yale School of Medicine 333 Cedar
Street, LMP 1094A, PO Box 208030 New Haven CT 06520-8030 or email it to laura.crawford@yale.edu.
These three items should be submitted to the Office of Global Health at least four months before you plan to travel.
Name:
Address:
Cell Phone Number:
Residency Program:
Current Training Year:
Beeper:
Email Address(es) and preferred email when abroad:
Languages spoken:
Proposed dates for requested elective: from ____________ to ________________
Description of Site (including location, brief history, and how you came to know of it)
Name of Clinical Site:

Affiliation:

Clinics:

ICU:

Location (i.e. rural, urban):

Laboratory and Radiology Capabilities:
On-site Preceptor

Name:

Specialty:

Email:

Contact Telephone (including country code):
Resident Responsibilities (if none, please state):

Inpatient:

Outpatient:

On-Call:
Your plan for housing:
Should your request be approved, you will be asked to sign a waiver from the Office of Global Health, register with the
State Department and Yale Emergency Contact, submit your travel plans to the Office of Global Health before departing,
and provide a cell phone number at which you may be contacted during your elective in an emergency situation and an
emergency contact in the US. Your preceptor’s evaluation should be sent to laura.crawford@yale.edu in the Office of
Global Health. You will also be asked to submit a brief report on the rotation to the Office of Global Health.
Approval by the Office of Global Health
_______________________
Asghar Rastegar, MD
_____________
Date
Form updated August 2011
Independent Site Request Form, Office of Global Health