Paul S. Lietman Global Health Travel Fellowship for Residents and Fellows
Application and Commitment Form
(This form must be accompanied by a completed “Request for Elective Rotation” form with
required attachments. GHPP Students must complete all *asterisked items*)
Part 1 - Background Information
1.1 Identifying Information
Applicant Name
Last:
First:
Citizenship
Citizenship: Select Citizenship If “Other” please specify
VISA Type:
Local Address
Street:
City:
MI:
State:
Contact Information
Zip:
Email:
Phone:
1.2 Rotation Related Information
Training Program
Status
Department
JHH
Resident
Fellow
JHBMC
Other, spec.
Other, spec.
NPI
Employee Number
Rotation Dates
From:
To:
Rotation Location
City:
Global Health
Pathways Program*
If you are applying through the GHPP, please indicate your track: Select Track
Country:
Name, Title:
Address:
Faculty Reference:
Email:
Phone:
1.2 Please list any relevant publications and honors:
1.3 Previous overseas travel to developing countries for reasons other than vacation/tourism.
-1Lietman Travel Fellowship
Email questions to: Emily Combs ecombs@jhu.edu
Country
Reason for travel
Year
Total
Time
-2Lietman Travel Fellowship
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Part 2 - Personal Statements
2.1 Career goals. Please describe your career goals/plans. (Maximum of 250 words)
2.2 Training goals. Please describe what you will be doing during your elective how you believe will
help you achieve your training goals. This must be narrative and not a copy/paste of your ACGME
training goals. (Maximum of 250 words)
Part 3 – Funding
Budget. Please identify the funding you will need to conduct the fellowship in your selected location.
Note: Paul S. Lietman Global Travel Fellowships are capped at $5000. Please: 1) the sum of expenses in large
categories should total the amount you are requesting; expenses beyond $5000 should not be included; 2) Use lines
marked “Other” to present other required expenses, enter category in left column; 3) cite your source for estimating
the amount; 4) enter expenses in USD. Budgets submitted indicate to reviewers the expected expenses but do not
influence decisions regarding award amount. The primary consideration for award amount is duration of rotation.
Typically, awardees in country for 4 weeks or less receive $3,500, 5-6 weeks can receive $4,000 and 6+ weeks are
eligible to release the maximum of $5,000 (however, these are merely guidelines).
Total Request
Item
Transportation
Housing
Food
Other
Other
Source of Estimate
Amount
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Part 4 - Other Funding
Have you submitted an application for funding of this rotation from additional sources other than the
Center for Global Health?
No
Yes If you have selected YES, please list and describe all.
Source of Funding
Amount Requested Status (Select)
(SelectOne)
(SelectOne)
(SelectOne)
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Part 5 - Commitments
Applicant:
4.1
Applicant agrees that if selected for this placement s/he will prepare a report
within three months of his/her return from the rotation.
Yes
No
4.2
Applicant agrees that if selected for this placement s/he will present on their
experience at the next Global Health Day following the completion of their
rotation provided that they are still in training at Hopkins.
Yes
No
4.3
Applicant agrees that if selected for this placement s/he will submit a
personal reflection statement and 5 high-resolution photos no later than 1
month after returning to Hopkins, and agrees to allow CGH the rights to
publish said photographs along with appropriate photo credit attribution.
Yes
No
4.4
Applicant certifies agrees that if selected for this placement all appropriate
vaccinations and other health requirements will be completed before
departure to the field.
Yes
No
4.5
*GHPP applicant certifies to complete all Global Health Pathways Program
specific requirements.** Not applicable for regular Lietman applicants.
Yes
No
APPLICANT SIGNATURE:
Signature of Application
______________
Date (mm/dd/yyyy)
Application Instructions:
 Complete and save this application
 Print and sign this application form.
 Download (see web page), complete, and save the “Request for Elective Rotation” form as an
electronic file; print the “Request for Elective Rotation” with all the required attachments. Have your
residency director sign the RER form.
 Obtain one recommendation from your mentor or other faculty member at Hopkins. (see form)
 Please send:
o Electronic, signed copy of the completed “Housestaff Travel Grant Application Form” and
completed “Request for Elective Rotation” in MS Word.
o Separate Word file with your rotation objectives as outlined in the “Request for Elective”
o You or your recommender may send an electronic version of the recommendation form.
 GHPP applicants, are also required to submit approval from the Osler Medical Residency (S. Desai or
N. Aggarwal) and an email to the GHPP Director, Yuka Manabe (ymanabe@jhmi.edu) from:
o Track 1: the country director (see webpage)
o Track 2: the research supervisor
Send all application materials by the due date to: jhsph.ghgrants@jhu.edu
-5Lietman Travel Fellowship
Email questions to: Emily Combs ecombs@jhu.edu