UTCOM Global Health Forms
STUDENT FORM 2:
STUDENT PRE-DEPARTURE CHECKLIST
This form is for the student’s reference only; it need not be turned in. All the steps here must be done in order
to receive UTCOM credit and/or funds for a global health experience.
STEP 1: COME TO PAPERWORK MEETING ON ____, TO HEAR OGH EXPLAIN STEPS, FORMS AND
THIS WHOLE PROCES. BRING WITH YOU IF POSSIBLE (IF NOT, DO WITH STEP 2):
STUDENT FORM 1, if you have not already handed that in
Proof of good academic standing from the registrar, if you have not already handed that in
Photocopy of current passport
STEP 2: ON YOUR OWN, AFTER OGH SAYS TO START STEP 2: COMPLETE & GET TO OGH TO
GET APPROVAL TO MAKE TRAVEL PLANS. YOUR DUE DATE: _____
Any leftover paperwork from Step 1
STUDENT FORM 3
STUDENT FORM 4. Request and go to a “travel consult” with UHS or your physician to complete this.
$100 non-refundable downpayment for housing/transportation. Payable to “University of Toledo.”
STEP 3: WAIT FOR OGH APPROVAL OF YOUR FORMS & TRIP BY ________. AFTER YOU GET IT,
OBTAIN THE FOLLOWING AND COPY OGH.
Photocopy of visa, if applicable
Photocopy of any other documents necessary for travel, if applicable
Proof of registration for the relevant Global Health course. Contact OGH if you need specifics.
Buy your flights, on your own or with a travel agency. Get OGH a copy of your itinerary.
Proof of insurance, which generally averages about $50/month, with the following minimum coverage:
a. Medical Expense (accident/sickness) in the amount of no less than $100,000 per incident, which
includes: Reimbursement for costs incurred or coverage for necessary medical expenses (treatment
prescribed by a physician or provided in a hospital) associated with accidental injury or
illness/disease occurring outside the US.
b. Accidental Death/Dismemberment in the amount of no less than $10,000, which includes:
Reimbursement for costs incurred or coverage for loss of life or loss of a limb(s) and/or eye(s).
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c. Emergency Medical Evacuation in the amount of no less than $50,000, which includes:
Reimbursement for costs incurred or coverage for expenses associated with physician recommended
medical transportation to a different facility or hospital for medically necessary treatment that is not
available locally.
d. Repatriation of Remains in the amount of no less than $25,000, which includes: Reimbursement for
costs incurred or coverage for the return of a body to one’s principle residence when the death
resulted from a covered injury or illness.
To accomplish this, you must buy insurance in the form of one of the following three plans or show
proof that your existing insurance meets requirements (a) – (d) above:
a. CMI's Study Abroad Plan B. http://www.cmi-insurance.com/travel-medical-insurance/view-all-plans/studyabroad.aspx
b. IMG's Patriot Exchange Program Standard Short-term Travel Plan Option B. http://www.imglobal.com/imgc.
insurance/international-student-insurance/patriot-exchange-program.aspx (click on brochure on left)
Aetna's Student Health Insurance Plan for UT Medical Students, through On Call International, at no cost to
students who have it, but all international medical expenses are "out of network" and thus reimbursed at 60%,
meaning students pay 40%. You must act to subscribe for international coverage. See details at:
http://www.aetnastudenthealth.com/schools/utoledo/medbrochure0910.pdf, page 67.
Proof of registration with the U.S. Department of State ( https://travelregistration.state.gov/ibrs/ui/).
In the case of travel without UTCOM faculty for over two weeks, copy of agreement (an email is fine)
between student and faculty or OGH staff that shows both parties know when you are going and that you
will be in touch weekly while onsite by email, phone, or Skype.
STEP 4: COME TO MANDATORY ORIENTATION ON __________ AND BRING WITH YOU:
Any paperwork from Step 3 that you have not copied already to OGH;
STUDENT FORM 5, filled out as much as you can. We will complete the rest on the spot..
A check for the balance of the housing/transportation fee, made payable to the University of Toledo.
OGH should contact you with the amount before orientation; prod us if not.
AT ORIENTATION, we take attendance. If you do not attend an orientation, you may be denied UT
credit or UT funds. We will also give you STUDENT FORM 6 (eval) to fill out on your flight home.
We do not require but do strongly recommend you also bring to orientation:
US Department of State Emergency Wallet Card, with U.S. embassy & local 911 contact information.
Find it at: http://www.travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html and the relevant info for
completing it at http://studentsabroad.state.gov/html-site/ToGo.html#card.
 the U.S. Department of State’s prep and pack lists (go to
http://studentsabroad.state.gov/pdfs/Preplist.pdf, and http://studentsabroad.state.gov/pdfs/Packlist.pdf)
 the U.S. Department of State’s country background information and country-specific information on
your destination country (go to http://www.state.gov/r/pa/ei/bgn/ and
http://travel.state.gov/travel/cis_pa_tw/cis/cis_1765.html).
STEP 5: PREP, PACK AND HAVE A GREAT TRIP!
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