INTERNATIONAL MEDICAL EDUCATION GLOBAL HEALTH TRIP REPORT WORKSHEET
[to be reviewed with trip advisor before submitting via http://umassmed.edu/oume/international-medicaleducation/global-health-trip-report/
GLOBAL HEALTH TRIP REPORT
INSTRUCTIONS FOR STUDENTS
Thank you for completing this Global Health Trip Report about your recent global health experience. The primary
purpose of this report is to help future students as they are looking for global health opportunities.
All past Global Health Trip Reports are accessible on the UMMS website, via the Lamar Soutter Library
eScholarship@UMMS webpage and the UMMS International Medical Education webpage.
To complete and submit your Global Health Trip Report
First: complete a draft version of the Global Health Trip Report using the IMEP-GHP Trip Report
WORKSHEET.
Second: the student should send the draft version of the IMEP-GHP Trip Report WORKSHEET to their
UMMS Elective Advisor for review. Remind the Elective Advisor that the final version will be posted on the
Lamar Soutter Library eScholarship@UMMS webpage and or the UMMS International Medical Education
webpage.
Third: When suggested edits have been incorporated, the student submits the final version of the Global
Health Trip Report via the online submission form on the UMMS International Medical Education website
(http://umassmed.edu/oume/international-medical-education/global-health-trip-report/).
THE REPORT…
DEMOGRAPHIC INFORMATION
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Your name: _________________________
Date of submission: ___________________
Year in Medical School: (select one of the options below)
o Summer between FOM1 & FOM2
o 2nd year (FOM2)
o 3rd year (CCE)
o 4th year (AS)
o 5th year
Expected Year of Graduation: ___________
Name of your UMMS Elective Advisor:
o First name
o Last name
o Email address
UMMS Elective Advisor's Home Department
o Anesthesiology
o Biochemistry & Molecular Pharmacology
o Cancer Biology
o Cell Biology
o Emergency Medicine
o Family Medicine & Community Health
o Medicine
o Microbiology & Physiology Systems
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INTERNATIONAL MEDICAL EDUCATION GLOBAL HEALTH TRIP REPORT WORKSHEET
[to be reviewed with trip advisor before submitting via http://umassmed.edu/oume/international-medicaleducation/global-health-trip-report/
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Neurology
Neurobiology
Obstetrics & Gynecology
Orthopedics & Physical Rehabilitation
Ophthalmology
Otolaryngology
Pathology
Pediatrics
Program in Molecular Medicine
Psychiatry
Quantitative Health Sciences
Radiology
Radiation Oncology
Surgery
TRAVEL INFORMATION
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Country to which you travelled: (select one of the options below)
o Argentina
o Bolivia
o Cameroon
o China
o Costa Rica
o Dominican Republic
o Ecuador
o Guatemala
o Haiti
o Hungary
o Ireland
o India
o Kenya
o Nicaragua
o People’s Republic of China
o Uganda
o United Kingdom
o Other – please specify
Other countries visited for education or service ____________
Region to which you travelled: (select one of the options below)
o Africa
o Asia
o Australia | Oceania
o Central America | Caribbean
o Europe
o North America
o South America
o Middle East
o Other - please specify
SITE INFORMATION
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Host Institution Name: _____________
Month and year of travel: _____________
Site Description (rural, clinic, university hospital): _____________
Placement Arrangement:
o List the person(s) and or organization(s) you contacted to set up this global health experience:
__________
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INTERNATIONAL MEDICAL EDUCATION GLOBAL HEALTH TRIP REPORT WORKSHEET
[to be reviewed with trip advisor before submitting via http://umassmed.edu/oume/international-medicaleducation/global-health-trip-report/
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Contact Phone: _____________
Contact email: _____________
EXPERIENCE INFORMATION
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Primary focus of the global experience (select one of the options below
o Language | cultural immersion
o Public health | community service
o Research
o Clinical
If you selected clinical, in which clinical field(s) did you gain experience during this experience? (select
all that apply)
o Cardiology
o Dermatology
o Emergency Medicine
o Family Medicine
o Geriatrics
o Hematology | Oncology
o Hospice Care | Palliative Care
o Infectious Diseases
o Internal Medicine
o Nephrology
o Neurology
o Ophthalmology
o Orthopedics
o Pathology
o Pediatrics
o Psychiatry
o Radiology
o Rheumatology
o Surgery
o Urology
o other (please specify)
Describe any necessary prerequisite, (eg, language or clinical proficiencies): ________
Host Institution Supervisor:
o Name, title, position: _____________
o Phone, email: _____________
TRIP EXPENSES | APPROXIMATE COST OF TRIP | OVERALL RATING
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Give a breakdown of the estimated costs of the different parts of your travel (eg, $1000 for airfare, $200 for
housing in a university dorm room, $300 for food, $200 for in-country travel related to study / work /
research): _____________________
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Provide the total of the different costs that you described in the previous questions. Do not include any
costs for recreation or entertainment: ______________
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List any sources of funding (and approximate amounts) that you received for this global health experience
(eg, $1000 from the Godkin Fellowship): _______________
Rate the Educational Value of this global health experience: (select one)
o excellent
o good
o poor
Comments regarding the educational value of this global health experience: ____________
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INTERNATIONAL MEDICAL EDUCATION GLOBAL HEALTH TRIP REPORT WORKSHEET
[to be reviewed with trip advisor before submitting via http://umassmed.edu/oume/international-medicaleducation/global-health-trip-report/
HEALTH MEASURES | SITE & LIVING CONDITIONS | PACKING & PREPARATION
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Describe any necessary health measures prior to, during, and after the experience (EG, visitors entering this
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country are required to carry vaccination history, student should consider PPD skin test 1-3 months after
returning from this country). ________________
Describe any tips regarding packing and preparation that might be helpful for future students who travel to
the same global health experience. ________________
Describe any positives and negatives about the location and Host Institution ________________
Describe any positive and negatives about the living conditions where you did this experience
________________
Any other advice to students and residents________________
SUMMARY | REFLECTION
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SUMMARY: Write a brief paragraph summarizing the degree to which your global health experience met your
learning objectives and contributed to your medical education and career aspirations.
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REFLECTION ON THE EXPERIENCE: Write one or two brief paragraphs describing what you learned about the
country and culture that you visited. Topics discussed may include: lifestyle and living conditions, migration
of immigrants to the US, religious and cultural beliefs and practices, health beliefs or practices, diseases or
health conditions, health care systems, immigrants from this country who now are living in the US.
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REFLECTION ABOUT THE EXPERIENCE IMPACT ON YOU: Write one or two paragraphs on any combination of the
following topics
o What you learned about yourself or your own country | culture
o The impact that the experience had on you
o What you learned from this experience
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