International Health Elective Application March 31, 2010
Office of Curriculum
International Health Elective
MIDS 6014 and MIDS 806G
Background
The School of Medicine offers curricular opportunities for students to participate in International
Health Electives at two different times during the medical school curriculum:
a. Summer between Year 1 and 2 (up to 8 weeks)
b. Year 4 (4 week elective)
Grading and Transcript Entry
Students who perform the elective in the summer between Years 1 and 2 will have an entry on their
transcript for zero credits and will be graded using a Pass/Fail system. The International Health Advisor
on the Lubbock campus will assign these grades. Students who perform the elective during Year 4 will
be graded according to the current Year 4 elective grading scheme. The International Health Advisor on
the student’s home campus will assign these grades.
Eligibility Criteria
Applicant:
1. Must be in good academic standing as validated by the Office of Student Affairs.
2. Must devote a minimum of four weeks to the elective work.
Application Process
The application process will proceed in two stages. In Stage 1, any student who wishes an
International Health Elective to appear on their transcript will submit a brief on-line application. These
applications will be reviewed for consistency with the mission of the Global Health Program of the
School of Medicine and qualifying proposals will receive approval within two weeks. In Stage 2,
students who receive approval will complete a full application and may at this time apply for financial
support for their elective. Students who seek financial support will be required to describe a specific
project that will be undertaken during the elective. These proposals will be reviewed by the
International Health Committee of the SoM and funding will be approved for the highest ranked
projects.
General Requirements for receiving Curricular Annotation
For an International experience to appear on a transcript, it must fulfill certain requirements based on
institutional Operating Procedures.
Most importantly, the site for the experience must conform to the requirements for an approved site
as described in TTUHSC operating Procedures as follows:
International Health Elective Application March 31, 2010
Approved Sites
(1) Universities or institutes of higher education with which TTUHSC has formal agreements or
MOUs,
(2) International organizations such as WHO, PAHO, UN, etc. where the USA has
representation,
(3) Teaching hospitals or health care organizations approved by the dean of the school and the
VPIMA, and/or
(4) One-time-sites of special pedagogic interest; provided prior approval of the dean of the
school and the VPIMA
If the site for the experience falls into category one above, the student should contact the International
Health Advisor prior to submitting an application for information on the capacity of the site and
guidelines for times available for the experience. If the site falls into one of the other categories, the
student should contact the International Health Advisor to determine the likelihood that the site could
be approved. For example, it may be possible to initiate and complete a Memorandum of
Understanding with the host institution in time to complete the experience. However, the student is
reminded that this is a legal document and completion of an agreement can take some time.
Student Evaluation
Student must have an evaluation form (MSIV) completed by the supervising host physician overseeing
the clinical experience in the country where the elective is conducted.
Student will keep a daily journal of their activities, insights, and lessons learned. Students will be given
the opportunity to share some of these insights upon their return.
International Health Elective Application March 31, 2010
Stage 1: Application for Elective Approval
Students who are interested in participating in an International Health Elective and wish to receive
curricular annotation on their transcript should submit an application at:
https://hscweb.ttuhsc.edu/som/curriculum/EPCApplication/Default.aspx.
This application will request information in 5 different areas:
1. Demographic Data: Contact information for the applicant
2. Destination Details: Enter information about the country where the elective will be performed
and specific locations within that country; the type of elective and proposed dates of travel
3. Contact Information: Enter names and contact information for any or all of the following:
A. TTUHSC Faculty Sponsor: this could be a TTUHSC faculty member with whom you will travel
B. Organization: If you will travel with a health-related organization (e.g. WHO, CDC, etc), enter
the full name of that organization
C. Host Institution: If there is a host institution with which TTUHSC has a Memorandum of
Understanding or Affiliation Agreement covering International Health experiences, enter the
name of the institution here
D. Faculty Contact at Host Institution: Insert the name of a faculty member who will be
responsible for overseeing your program in the host country. Ideally, this will be a faculty
member at a medical school in the host country.
E. Other: If you cannot identify an individual who fits categories 4A-D, or wish to list other
contact individuals, enter their contact information here.
4.
Pre-elective Explanation of Proposed Site Environment: Describe what you intend to do during
your elective experience in 200-500 words. For example, describe specific clinics in which you
will participate, or existing programs you will join.
5.
Required Data for Destination
A. State Department Information
http://www.state.gov/misc/list/index.htm
Navigate to the page for the country to which you intend to travel and copy and paste the URL
for the front page for this country. Summarize any travel warnings that are listed for this
country.
The Centers for Disease Control also publish information about travel warnings. Go to:
http://wwwnc.cdc.gov/travel/destinations/list.aspx, select your country of interest and click on
the “Travel Notices in Effect” link. Make sure that you final list of travel warning include
information from both sites (they should be the same).
B. Immunization Requirements: The CDC also publishes recommendations for immunization
requirements for every recognized country. Using the same page that you used to collect travel
notices, click on the “Preparing for your trip to ____” link and provide a list of immunizations
recommended for this country. (Note that your standard immunizations will also need to be up
to date)
International Health Elective Application March 31, 2010
Stage 2A: Completion of Application
Upon receipt of approval, each student should submit a complete application to the International
Health Elective Coordinator (Sophia Pena, Sophia.pena@ttuhsc.edu).
1. Review HSC OP 77.08; Student Travel Policy (Appendix A)
2. Complete Personal and Logistic Information Form (Appendix B)
3. Description of Elective Activities (either as part of Appendix B or on a separate sheet)
Due Date for MSI/II electives: April 14, 2010
Due Date for Year 4 electives: April 28, 2010
International Health Elective Application March 31, 2010
Stage 2B: Application for Financial Support
Financial support for International Health Electives may be available from several sources. However,
students are advised not to rely on the availability of funds as a deciding factor in applying for an
International Health Elective:
1. School of Medicine Scholarships: Scholarships of up to $1,500 have been provided in the past
and are organized through the Office of Development at TTUHSC. In the past, donors have
included individual donors, the Office of the President and the F. Marie Hall Office of Rural and
Community Health (http://www.ttuhsc.edu/ruralHealth/). The exact number of SoM
scholarships for 2010-2011 may vary from year-to-year as fund-raising is an ongoing process.
As of March 31, 2010, there is approximately $4,500 available for these scholarships. At least
$1500 will be available for students traveling to Ethiopia for Year 4 electives.
2. TTUHSC Center for International and Multicultural Affairs (CIMA: http://www.ttuhsc.edu/cima/)
will fund scholarships from funds collected as part of student fees. $4,000 will be provided to
the SoM from this source and $3000 has been committed to the new MSI/II elective activity in
Santiago De Compostela, Spain.
3. Deans Scholarships: Two $1000 scholarships have been provided by the Dean for students
traveling to Thailand in summer 2010.
In order to qualify for a scholarship programs, applicants should complete Appendix C: Research
Project Description. Students should describe a research project that will be performed as part of the
elective. In 1000 words or less, the applicant should provide the following:
a.
b.
c.
d.
Background for the project, describing the area of need being addressed
Hypothesis to be tested
Specific activities to be performed
Method for reporting of results.
The International Health Committee will review the proposals and top ranked proposals will be eligible
for scholarship awards.
International Health Elective Application March 31, 2010
Stage 3: Preparation for Trip
Each student will present the following documentation to the International Health Elective Coordinator
prior to travel
_____ Required travel documentation (valid passport, visa for host country)
_____ Travel Release and Indemnification Agreement (HSC OP 77.08a; see Appendix D)
_____Authorization for Emergency Medical Treatment (HSC OP 77.08b; see Appendix E)
_____ Release and Hold Harmless Agreement and Authorization for Emergency (see Appendix F)
These three forms should be witnessed by a Notary Public
_____ Emergency Contacts (see Appendix G)
_____ Proof of Immunizations to be completed by _____________ (2 weeks pre-departure)
_____ MEDEVAC coverage, international insurance to be completed by ____ (2 weeks pre-departure; see
Appendix H)
_____ Register with US embassy in host nation (Register online @ https://travelregistration.state.gov/ibrs/ui/)
International Health Elective Application March 31, 2010
Stage 4: Post-Trip Requirements
A. Contact International Health Advisor
Student must schedule a meeting with his/her TTUHSC faculty mentor/advisor for debriefing within two weeks
of return.
B. Host Sponsor Evaluation to be completed by ___ /___ / ___ (1 month post-return)
C. Submit Post-elective report for use by future students
Medicine in a foreign country can be just as foreign as the language, food, and culture at times.
Students are highly encouraged to keep a journal while they are away in hopes of retaining the detail of
their experience. This debrief is designed to assist you in evaluating your experience. Upon returning
please describe your experience in a two to four page paper including the following information.
Describe your experience with medicine in a foreign country. Touch upon the environment in
which you worked and the people with whom you worked.
Describe the health care system in the country of intent. Briefly compare it to that of the United
States.
What was the most difficult part of working in a foreign country?
How did participating in the International Health Elective change you?
The written debrief must be turned into the International Health Advisor within one month of return from the
international health experience. Students will share presentation/poster with campus colleagues and/or at
national convention within two months of return.
D. Make presentation to students on your campus
Student is encouraged to share their experiences at an annual TTUHSC International Medicine Club meeting.
Student is encouraged to help with orientation for future students and to participate in global health related
educational activities within the SoM curriculum.
International Health Elective Application March 31, 2010
TTUHSC School of Medicine
International Health Elective Pre-application
Application due February 16, 2010
This form will be completed online
Demographic Data
First Name: _____________________
Last Name: ____________________
Campus: _________________
Class: _______________________
Email: _______________________________________
Telephone: ____________________________________
Destination Details
Country of intent: __________________________________
Location within target country: ________________________________
Type of elective: MSI/II Summer ___
Year 4 Elective ___
Proposed dates of Elective: __________________________________
Contact Information (enter only if available)
A. TTUHSC Faculty Sponsor: _______________________
B. Organization: ________________________________
C. Host Institution: ______________________________
D. Faculty Contact at Host Institution: ___________________________
E. Other: ________________________
Pre-elective Explanation of Proposed Site Environment
Briefly describe the activities in which you will participate (200-500 words). Include three learning
objectives for your elective.
Required Data for Destination
State Department Status: (Insert URL of most recent report from State Department and/or Centers for
Disease Control)
List any travel warnings in past 12 months
Immunization Recommendations
CDC Recommendations: (Insert URL for relevant CDC site)
List of recommended immunizations:
Funding
If approved, will you seek financial support from the SoM?
Yes___
No ___
International Health Elective Application March 31, 2010
Appendix A
TTUHSC OP 77.8: Student Travel Policy
See Attached PDF
International Health Elective Application March 31, 2010
Appendix B
Personal and Logistical Information
Please check one of the following according to your year in school:
□ Summer Year 1 – 2 Application
□
Year 4 Elective Application
Personal Information
_____________________________
Last Name
________________________
First Name
____________
Middle Initial
_____________________________
Phone number
________________________
Email address
_____________________________
Street Address (permanent)
________________________
City, State
________________________
Start date of elective
____________________
End date of elective
________________________
Expected date of graduation
____________________
Current year in medical school (MS I, II, etc.)
______________
Zip
____________________
TTUHSC Faculty Mentor
Logistical Information
Host Supervising Physician
(or other medical professional
Responsible for student)
________________________
(Name)
______________
(Title)
________________________
(Phone)
______________
(Fax)
________________________
(Email)
Site of Elective Activity
________________________
(Street Address)
________________________
(City)
Language spoken in Host Country ____________________________
Language(s) Spoken by Student ________________________
______________
(Country)
International Health Elective Application March 31, 2010
The learning objectives for the student include:
1.
2.
3.
Proposed Activities:
1.
2.
3.
________________________
________________
Signature of Applicant
Date
Academic Standing
I have reviewed this student’s academic record and confirm that s/he is in good academic standing
________________________
________________
Signature of School Official*
Date
* Associate Dean for Academic Affairs, Assistant Dean for Student Affairs, Assistant Dean for Basic Science Curriculum,
Assistant Dean for Clinical Science Curriculum
Required Data for Destination
State Department Status: (Insert URL of most recent report from State Department and/or Centers for
Disease Control)
List any travel warnings in past 12 months
Immunization Recommendations
CDC Recommendations: (Insert URL for relevant CDC site)
List of recommended immunizations:
International Health Elective Application March 31, 2010
Appendix C
International Health Elective
Research Project Description
_____________________________
Last Name
________________________
First Name
____________
Middle Initial
____________
MS Year
_____________________________
Location of Elective
Project Title:
________________________________________________________________________________
Background for the project, describing the area of need being addressed
Hypothesis to be tested
Specific activities to be performed
Method for reporting of results. (Include information on impact of your trip on the local population).
International Health Elective Application March 31, 2010
Appendix D
HSC OP 77.08a: Travel Release and Indemnification Agreement
See attached PDF
International Health Elective Application March 31, 2010
Appendix E
HSC OP 77.08b: Authorization for Emergency Medical Treatment
See Attached PDF
International Health Elective Application March 31, 2010
Appendix F
Release and Hold Harmless Agreement and Authorization for Emergency Medical Treatment
I,__________, a Texas Tech University Health Sciences Center student have the opportunity to participate in the
International Health Elective, to take place in . I have the opportunity to gain academic credit through participation in the
program. As a Student of Texas Tech University Health Sciences Center, I realize that I am an ambassador of Texas Tech
University Health Sciences Center and, therefore, am subject to all rules governing the conduct of student life, as defined in
the Texas Tech University Health Sciences Center Student Affairs Handbook, Code of Student Conduct at Texas Tech
University Health Sciences Center. Furthermore, I understand that I will be subject to disciplinary action in accordance with
these rules.
I authorize my host institution to release any records that the institution deems necessary to the appropriate
departments at Texas Tech University Health Sciences Center. I assume complete responsibility for my safety and welfare. I
hereby give my consent for any medical treatment that may be required during my participation in the program with the
understanding that the cost of any such treatment will be my responsibility. I further give my consent for the release of any
health information that may be necessary to facilitate such medical treatment. I hold TTUHSC, its representatives, agents,
or other responsible party harmless from any liability, neglect, or otherwise, with regard to seeking emergency medical
treatment on my behalf. I fully authorize emergency medical treatment on my behalf in the event of such need. I
understand that I will be traveling during the program by plane, train, hired bus, and other modes of transportation that
may or may not be owned by or under the control of Texas Tech University. As a participant, I voluntarily choose to travel
by these conveyances. I am aware of the dangers associated with such travel, including the possibility of injury and even
death. I understand that my choice of transportation during this course of study is voluntary on my part, and I affirm my
desire to travel as outlined above.
I recognize and understand that the possibility of political unrest exists on any occasion in which there is travel to
or from a location outside of the United States. I am aware of the dangers of such political unrest, and understand that my
choice to travel abroad is voluntary on my part, and I affirm my desire to do so.
I agree to assume full responsibility for my safety and the safety of my property at all times. I understand that I
may sometimes be traveling in areas having higher than average rates for crime, especially theft of property. I further agree
to assume full responsibility for my own safety and the safety of my property at all times while participating in the
International Health Elective.
In consideration of being allowed to participate in the program and the above mentioned activities, I, the
undersigned, do hereby release, indemnify, and hold harmless the Texas Tech University system, its Board of Regents, all
system officers, agents, and employees, the Office of Student Affairs, the Office of Curriculum, from any and all liability
claims, demands, and actions whatsoever arising out of or related to any loss, damage, or injury, including death, which
may be sustained by me or to any property belonging to me. The terms hereof shall also serve as a release and an
assumption of risk for my heirs, executor and administrator, and for all members of my family, and may be pleaded as a bar
to litigation. Jurisdiction and venue over all matters related to the program and/or this release shall lie exclusively in
Lubbock, Lubbock County, Texas.
I am above the age of 18 years and have read this Release and Hold Harmless Agreement and understand and voluntarily accept the
terms.
____________________________________
Signature of Student
____________________________________
Printed Name
THE STATE OF TEXAS COUNTY OF _________________________________
SUBSCRIBED AND SWORN TO BEFORE ME by the said __________________________
on this the _____________________ day of ___________________________, 20___.
________________________________________________
NOTARY PUBLIC in and for the state of Texas
________________
Date
International Health Elective Application March 31, 2010
Appendix G
Emergency Contact Information
United States Emergency Contact Information
___________________________________
Name
________________________
Phone number
___________________________________
Email address
___________________________________
Relationship to Student
Host Country Emergency Contact Information
___________________________________
Name
___________________________________
Email address
___________________________________
Relationship to Student
_______________________
Phone number
International Health Elective Application March 31, 2010
Appendix H
Information on Selecting Insurance for Travel Abroad
Students who participate in TTUHSC International Health Elective must ensure that they purchase sufficient
insurance coverage for the period of time outside of the USA.
Insurance policies should provide for adequate health and accident coverage as well as coverage for emergency
medical evacuation and repatriation of remains in the case of death. Many countries will require proof of
insurance as a condition for obtaining a visa to enter the country to study.
Emergency Medical Evacuation & Repatriation and Repatriation of Remains: Texas Tech University Health
Sciences Center students must select coverage for MEDEVAC and repatriation of remains.
Health & Accident Insurance: First, check with your domestic insurer to find out whether or not your domestic
health and accident policy will cover you while you are out of the U.S. If your domestic policy does not cover you
for health and accident, then you will have to purchase basic coverage. (A list of insurance companies who
provide this coverage for students participating in study abroad follows.) Many domestic policies require you to
pay at the time of treatment and apply for reimbursement. It is important for you to know what documentation
you must provide in order to be reimbursed for out-of-pocket medical expenses while abroad. Time of required
payment is an important consideration when you are traveling on limited funds.
Payment and reimbursement overseas: The student will normally have to pay for medical service and fill out a
claim form to be returned to the home company for reimbursement. It is imperative for students to know the
limits of their coverage and to carry at least one claim form to be signed by appropriate medical persons abroad
to facilitate reimbursement.
How much insurance do you need? Students should research rates with several different companies. Call more
than one company and tell them where you are going, what traveling you will be doing and ask what they think
should be adequate coverage.
Review a Number of Policies. It is best to review a number of policies and select the one that is most
appropriate for your needs. A list of companies providing this coverage and their information follows. It is your
responsibility to study them carefully and select the one which best fits your needs. Travel can be physically and
medically rigorous and the possibility of illness or an accident is always a concern. Therefore, it is strongly
advised that participants have a physical examination to receive assurance from a physician that they are able to
participate
Trip Cancellation/Trip Interruption Insurance: You may wish to consider purchasing trip cancellation/trip
interruption insurance which pays out if you are prevented from taking your trip or if the trip is interrupted. The
details and type of insurance coverage available varies from company to company. You should review the
coverage provided by a specific policy. Cancellation insurance may be purchased through STA Travel and
through Wallach and Company Insurance’s Health Care Global plan.
International Health Elective Application March 31, 2010
MEDEVAC and Insurance Coverage Providers
Students may consider coverage from International SOS Assistance, the provider through which undergraduate
study abroad students receive coverage. TTUHSC does not endorse any particular insurance company. This list is
provided to assist your investigations only. A comprehensive list may be obtained at:
http://travel.state.gov/travel/tips/health/health_1185.html
Gateway International
www.gatewayplans.com
1-800-282-4495
Associated Insurance Plans International (AIP)
www.a-i-p-i.com/international.htm
1-800-452-5772
Cultural Insurance Services International (CISI)
www.aifs.com/cisi/americansoverseas.htm
CMI Insurance Specialists
www.studyabroadinsurance.com/
410-583-2595
HTH Worldwide Insurance Services
www.hthstudents.com/voluntary.cfm
1-800-242-4178
International SOS Assistance
www.internationalsos.com/buymembership/
1-800-505-5450
International Medical Group (IMG)
www.istudentinsurance.com
1-800-628-4664
MEDEX Assistance Corporation
www.medexassist.com/indiv_travmed_intl.cfm
1-800-732-5309
Wallach
www.wallach.com/hcglobal2000.asp
1-800-237-6615
STA Travel
http://www.statravel.com/Statravel/travelinsurance/