CENTER FOR GLOBAL HEALTH
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
APPLICATION FOR CLINICAL ELECTIVES
1.
Date of Application
(month/day/year)
Personal Information
2.
Last Name (Family/Surname)
3.
First Name
4.
Home Address (street, city, state, postal code, country)
5.
Home Phone Number
6.
Email Address(es)
7.
Emergency Contact
(
Male
Female)
(Name, Relationship, Phone Number)
8.
Date & Place of Birth
9.
Citizenship
10.
First Language
11.
English Skill (fluent; good; fair)
12.
TOEFL Score (enclose official score report)
(month/day/year)
[Required for schools where English is not teaching language; minimum acceptable TOEFL
scores are 250 (for computer-based test) and 600 (for paper-based test). For TOEFL® iBT,
minimum scores are: 24 (Speaking) + 24 (Listening) + 20 (Reading) + 20 Writing. ]
13.
Your Medical School Name/Location
14.
Degree you will Earn (e.g. MD or MD/PhD)
15.
Expected Graduation Date
16.
Date to Begin* Clinical Elective(s) @ Penn
(month/day/year)
(month/day/year)
(elective must start and end on elective dates indicated on our
website: http://www.med.upenn.edu/globalhealth/intl_students.shtml)
17.
# of Months to Spend @ Penn
(two month maximum)
1 month
2 months
Processing Your Application
This application must be sent to the Center for Global Health by official representative of your home medical school.
The following must be included in your application:
page 1: personal information
proof of personal health insurance that will cover student
page 2: elective selection and student attestation
while in the USA
page 3: medical school official certification
proof of $2050 per month to cover living expenses while
page 4: immunization record (in English)
student is in the USA
official copy of student transcript (in English)
photocopy of passport identification page
copy of TOEFL score report
(not required if English is the teaching language of the
home medical school)
Be sure to review “Preparing for Travel” and “Welcome to Philadelphia” information on CGH website, as early as possible:
http://www.med.upenn.edu/globalhealth/intl_students.shtml
*If you do not qualify for a visa waiver please allow 3-6 months to arrange visa
1 of 4
Perelman School of Medicine/ Center for Global Health / globhlth@mail.med.upenn.edu
09 08 15
CENTER FOR GLOBAL HEALTH
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
APPLICATION FOR CLINICAL ELECTIVES
Clinical Electives Ranking
Please note your clinical electives preferences by ranking every course that would be acceptable to you. The more courses you rank, the
more likely you are to be placed. The courses listed are typically available; however, they are not guaranteed and it is possible that there
will be no spots available for you in any of the courses you rank. Rank “1” for the elective most desired; rank higher #s for less desirable, but
acceptable; do not rank unacceptable electives). You are obliged to start and end your elective at Penn on the specific dates posted on our
website: http://www.med.upenn.edu/globalhealth/intl_students.shtml. No exceptions to this policy will be made. Fill in the dates in the
section below the ranking table.
Elective Course
ANE300
Elective Course
Rank
Elective Course
Rank
ORT330 Ortho Extremity Reconstr
PSY303 Child/Adoles/Famly Psych
Pain Medicine
OTO302 Otorhinolaryng Prim Care
PSY311A
PAT301
RAD320 Vasc/Interventl Radiology
ANE303
GEN303/303A
Rank
Anesthesiology
Medical Genetics
MED314D
PED302A
Neonatology
PED302D
Neonatal ICU
SUR300D
General Surgery
MED324A/D Hematology/Oncology
PED305D
Well Newborn
SUR312A
Cardiac Surgery
MED334A/D/E
Gastroenterology
PED314
Pediatric Cardiology
Nephrology
PED323
Pediatric Oncology
SUR318
Vascular Surgery
Infectious Diseases
PED324
Pediatric Hematology
SUR341
Transplant Surgery
MED343D/E
MED354A
RON300
Consult Psychiatry
Cardiac Electrophysio
MED316A
Cardiology
Clinical Pathology
Radiation Oncology
SUR314 Congenital Cardiac Surg
MED364A/D/E Pulmonary Disease
PED334 Pediatric Gastro-Intestinal
SUR345A
MED365
Cystic Fibrosis
PED344
Pediatric Nephrology
SUR346
Pediatric Urology
MED384A
Rheumatology
PED354 Pediatric Infectious Disea
SUR362
Plastic Surgery
MED394A/D
Endocrinology
PED367
Pediatric Pulmonology
SUR363 Pediatric Plastic Surgery
Critical Care
PED394
Pediatric Endocrinology
SUR364 Plastic/Reconstrc Surgery
MED410D
NSG300
Neurosurgery*
PMR300 Rehabiliation/Musculoske
ORT304
Pediatric Orthopedics
PMR301
ORT306
Sports Medicine
PSY300
SUR365
Urology
Surgery Trauma
Pediatric Rehabilitation
Inpatient Psychiatry
* for Neurosurgery, CV and letter of recommendation must be submitted as part of this application
Core Clerkships Must be Completed Before Arriving @ Penn – Please fill in details below
Core Clerkship
Duration
(# of weeks)
Date
Completed
Grade
Medicine
Obstetrics/Gynecology
Pediatrics
Psychiatry
Surgery
Student Attestation – Please check each item and sign at the end of this section
The information I have provided in my application form and all attachments is accurate. If I am accepted and enrolled at Penn, I
understand that I remain a student in my home school and that the ultimate responsibility for patient care resides with the University
of Pennsylvania Perelman School of Medicine (hereafter referred to as PSOM) and its staff
will respect the confidential nature of all medical records and personally identifiable information related to patients
will act prudently within the limits of my knowledge, experience, and training; follow policies related to procedures and etiquette; and
wear attire acceptable to the PSOM
shall respect all property belonging to the PSOM and its affiliated institutions and I understand that I will be responsible for the repair
or replacement of any property damaged or destroyed by me
will be responsible for my own housing and transportation to and from the PSOM
understand that if I am unable to attend scheduled activities, I must notify the PSOM and my home school
certify that I have no preexisting conditions that would preclude or adversely affect me from being in any clinical areas or
participating in the Program. I am not aware that I have any infectious disease.
Signature________________________________________________________
Date___________________________
Be sure to review “Preparing for Travel” and “Welcome to Philadelphia” information on CGH website, as early as possible:
http://www.med.upenn.edu/globalhealth/intl_students.shtml
*If you do not qualify for a visa waiver please allow 3-6 months to arrange visa
2 of 4
Perelman School of Medicine/ Center for Global Health / globhlth@mail.med.upenn.edu
09 08 15
CENTER FOR GLOBAL HEALTH
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
APPLICATION FOR CLINICAL ELECTIVES
International Medical School Official Certification
For Completion by Dean/Designated Official of Student’s Home Medical School
STUDENT:
Last Name :
First Name:
This is to certify that the medical student named above is in good standing at this institution, that the information
provided on pages 1 and 2 of this application is correct, and that the student does have our permission to enroll
for clinical electives at the University of Pennsylvania Perelman School of Medicine. The student has completed
all required core clerkships (as noted on page 2). The student is covered by personal health insurance (attach
proof) which covers the student while away from our school and in the United States. In addition, the signature
below serves to certify that we have no record of this student’s ever having engaged in criminal activity of any
kind.
Important: Within a few weeks of the clinical elective end date, course directors submit evaluations via OASIS,
an online system. The Registrar’s Office notifies students by email when the student can access the evaluation
online. It is the student’s responsibility to forward the evaluation to their home institution, if required. URL to view
sample evaluation: http://www.med.upenn.edu/globalhealth/documents/MedicalStudentSampleEvaluation.pdf
Additional forms requested by student or student’s home school cannot be completed, signed, or sealed.
MEDICAL SCHOOL OFFICIAL: Last Name :
First Name:
Official Title:
Email Address:
Medical School Name:
Location: (city/country)
Is instruction at your medical school in English?
Yes
No
(if English is not the principal language of instruction, student’s TOEFL exam results must be provided)
Signature of Medical School Official
Date
Application Submission
Complete application must be sent to the Center for Global Health by the official
representative of the home medical school. The application must include:
page 1: personal information
page 2: elective selection and student attestation
page 3: medical school official certification
page 4: immunization record (in English)
official copy of student transcript (in English)
copy of TOEFL score report
(not required if English is the teaching language of
the home medical school)
proof of personal health insurance that will cover student
while in the USA
proof of $2050 per month to cover living expenses while
student is in the USA
photocopy of passport identification page
Scan complete application to send as email attachment to: globhlth@mail.med.upenn.edu or mail hard
copy to:
Center for Global Health / U of Penn Perelman School of Medicine / 240 John Morgan Bldg. / 3620 Hamilton Walk / Phila, PA 19104-4882
Be sure to review “Preparing for Travel” and “Welcome to Philadelphia” information on CGH website, as early as possible:
http://www.med.upenn.edu/globalhealth/intl_students.shtml
*If you do not qualify for a visa waiver please allow 3-6 months to arrange visa
3 of 4
Perelman School of Medicine/ Center for Global Health / globhlth@mail.med.upenn.edu
09 08 15
GLOBAL HEALTH PROGRAMS
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS
IMMUNIZATION RECORD
APPLICANT NAME: Last
First
BIRTHDATE
The University of Pennsylvania Perelman School of Medicine (Penn) requires all of the information listed below for a student to be
considered for placement. *Quantitative results require lab reports indicating titer and reference range. This form must be completed,
signed and dated by a health care provider. Applicants should be free from symptoms of infectious disease upon arrival. Applicant: If
you become ill with a communicable disease while at Penn, you must notify the Center for Global Health and your course
director/mentor.
MEASLES, MUMPS, RUBELLA (MMR)
Two doses of MMR are required (1st dose must be administered after the 1st birthday and 2nd dose a minimum of 4 weeks later).
who have not had MMR as specified may satisfy this requirement with the alternate regimen listed below OR positive titers
Students
MMR Dose 1 ____/____/____ Dose 2 ____/____/____
Alternative regimen OR positive *titer verifying immunity
MEASLES
Dose 1 ____/____/____ Dose 2 ____/____/____
OR
*Titer quantity _________
Lab report attached
MUMPS
Dose 1 ____/____/____
OR
*Titer quantity _________
Lab report attached
RUBELLA
Dose 1 _____/____/____
OR
*Titer quantity _________
Lab report attached
HEPATITIS B Requirement: Three doses (doses one and two given four weeks apart, and the third dose at least 4 to 6 months after the
first dose) AND a blood test showing *titer quantity/quantitative result (lab report, indicating titer and reference range required).
Dose 1 ____/____/____ Dose 2 ____/____/____ Dose 3 ____/____/____ AND *Titer quantity _________
Lab report attached
______________________________________________________________________________________________________________
VARICELLA (Chicken Pox) Requirement: Two doses of chicken pox vaccine are required at least one month apart (must be
administered after 1995) OR positive *titer verifying immunity (for positive titers, lab report including reference range, is required).
Dose 1 ____/____/____ Dose 2 ____/____/____ OR *Titer quantity _________
Lab report attached
_______________________________________________________________________________________________________________
TETANUS-DIPHTHERIA and PERTUSSIS (Tdap) Requirement: One dose administered in 2005 or later.
Dose 1 ____/____/____
________________________________________________________________________________________________________________
POLIO Requirement: Student must have completed primary series of polio immunizations – note below date series was completed.
Oral Polio Vaccine (OPV) ____/____/____
OR
Enhanced Inactivated Polio Vaccine (E-IPV) ____/____/____
________________________________________________________________________________________________________________
TTBI (Test of Tuberculosis Infection) Requirement: Two PPDs OR one QuantiFERON/IGRA, all within 12 months of the requested
elective start date (regardless of prior vaccination with BCG). Any student with a positive TTBI must include with this application reports
of the positive reaction, subsequent chest x-ray, and a TB symptom check done within 12 months of the elective start date.
Dates and results of last two PPD tests: ____/____/____
Negative
Date and result of QuantiFERON/IGRA blood test for TB infection
Positive ____/____/____
____/____/____
Negative
Negative
Positive OR
Positive
**Reminders**
1) Both PPDs must be done 1 year or less before the elective start date.
2) TTBI (PPD or QuantiFERON/IGRA) positive? If yes, check box and attach radiology report:
INFLUENZA Requirement: Students must have current influenza vaccine(s) if they will be at Penn anytime in October through March.
Please note that if you received your flu vaccine in a country in the southern hemisphere we may require re-vaccination.
Flu Vaccine Date ____/____/____
Health Care Provider
Print Name_____________________________________________________________
Phone #______________________________
Signature_______________________________________________________________
Date_________________________________
Address________________________________________________________________________________________________________
Be sure to review “Preparing for Travel” and “Welcome to Philadelphia” information on CGH website, as early as possible:
http://www.med.upenn.edu/globalhealth/intl_students.shtml
*If you do not qualify for a visa waiver please allow 3-6 months to arrange visa
4 of 4
Perelman School of Medicine/ Center for Global Health / globhlth@mail.med.upenn.edu
09 08 15