Global Health Leadership Program
Clinical Rotation Application and Commitment Form
Eligibility and Selection Process
1. 3rd and 4th year medical students that have completed the following core clerkships: Internal
Medicine and either General Surgery or OBGYN. Preference will be given to 4th year medical
students.
2. Selection will be based on personal qualities, academic and extracurricular records,
demonstration of strong interpersonal and organizational skills, a well-developed sense of ethics,
and a demonstrated interest or commitment to global health and reducing healthcare disparities.
Part 1 - Background Information
1.1 Identifying Information
Select Prefix Last:
Applicant
JHED
First:
MI:
ISIS ID
Date of Birth:
Citizenship
Citizenship: Select Citizenship If “Other” please specify
VISA Type:
Passport Number:
Expiration Date:
Local Address
Street:
City:
Contact Information Email:
Academic Status
State:
Zip:
Phone:
School: Select School
Department:
Area of Concentration:
Expected Graduation Date:
1.2 Clinical Site Information
Site Location
Pune, India
Rotation
Rotation Dates: Select Rotation Date
Rotation of Interest:
Medical Areas of Interest:
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1.3 Please list any relevant publications and honors:
1.4 Please provide your language skills:
Please list below your language skills. If you only speak English please select the “English Only”
button. If you have skills in languages in addition to English please list each language and your level of
proficiency in both conversation and reading/writing.
ENGLISH ONLY
Proficiency
Language
Speech/Conversation
Reading Writing
Select Proficiency
Select Proficiency
Select Proficiency
Select Proficiency
Select Proficiency
Select Proficiency
1.5 Have you ever lived and/or worked in a developing country?
No
Yes (please describe)
1.6 Personal Statements
1.6.1 Please describe your interest and future goals in global health (maximum of 250 words)
1.6.2 Please describe any past activities in global health research or practice (maximum of 250
words)
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1.6.3 Why do you wish to complete this elective and what would you hope to gain from participating?
1.6.4 What quality improvement project ideas do you have with your current knowledge of the clinical
setting? (Naturally these are just brainstorms, considering you have yet to visit the setting.)
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Part 3 - Commitments
Applicant:
4.1
4.2
4.3
4.4
4.5
4.6
Applicant agrees that if selected (and student accepts) for this
course s/he will complete the full term of the international elective
site (at least 4 weeks) except in extenuating circumstances.
Applicant agrees that if selected for this course s/he will complete
the mandatory pre-departure training before travel to the elective
site, which will be a combination of online and in person trainings on
the following topics:

Overview of institution resources and requirements for abroad
electives including travel clinic, insurance topics, ISOS

Didactic global health topic content and case studies

Ethics modules

Clinical simulations sessions: resuscitation, vaginal delivery

Research preparation modules

Leadership and management training modules/case studies

Meeting with students from SOM, SON, SPH to address predeparture concerns, issues encountered from the online sessions,
project ideas, etc.
Applicant agrees that if selected s/he will develop and complete (or
at least have feasible plan of completion) a project.
Applicant agrees that if selected s/he will participate in the postdeparture debriefing, which is an in person meeting after rotation at
the clinical elective site to share experiences, present project
progress and discuss any issues.
Applicant agrees that if selected for this course all appropriate
vaccinations and other health requirements will be completed
before departure to the field.
Applicant agrees to conduct oneself with the highest integrity and
uphold the reputation of Johns Hopkins University.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
APPLICANT SIGNATURE:
Signature of Applicant
_______________
Date (mm/dd/yyyy)
Application Instructions:
1. Complete and save this signed application as an electronic file.
2. Obtain one recommendation using a GHLP recommendation form from your advisor or another
faculty member at Hopkins. The recommenders should submit the form directly to Emily Combs |
ecombs@jhu.edu with the subject “GHLP LOR __student name__”
3. Obtain and submit a copy of your unofficial transcript.
4. Submit your current curriculum vitae (please highlight relevant experiences/accomplishments)
5. Submit a scanned copy of your passport.
6. Please submit all forms to Emily Combs | ecombs@jhu.edu
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