Intl Medical Student Applicationform Research 120712

GLOBAL HEALTH PROGRAMS
VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS RESEARCH APPLICATION 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Date of Application Last Name (Family/Surname) First Name Home Phone Number Email Address(es) Emergency Contact
(Name, Relationship, Phone Number) ( Male Female)
(month/day/year) (month/day/year) (month/day/year)
Home Address (street, city, state, postal code, country)
Date & Place of Birth Citizenship First Language English Skill (fluent; good; fair) TOEFL Score (enclose official score report)
(Required for schools where English is not teaching language)
Your Medical School Name/Location Degree you will Earn (e.g. MD or MD/PhD) Expected Graduation Date Date to Begin Research @ Penn * # of Months to Spend @ Penn
Please Describe Your Research Background & Interests (~ 1 page) IMPORTANT: LIST FACULTY @ PENN WITH WHOM YOU WOULD LIKE TO TRAIN:
To find faculty: go to:
http://www.med.upenn.edu/bgs/faculty_search.shtml
Complete Form: Once you have completed this form electronically, please save and attach in an
email to globhlth@mail.med.upenn.edu, along with CV and personal statement. If we are able to find a placement for you, Global Health Programs will send you instructions for the provision of documents required to complete this application (see below).
22.
Checklist of Documents Required to Complete Application (only if Global Health Programs GHP succeeds in placing you)
official copy of TOEFL score report
(not required if English is the teaching language of the home medical school) immunization record (in English; see following page)
medical school certification and student attestation proof of personal health insurance that will cover you while in the USA
Note: within three weeks of placement, Penns International Student and Scholar Services (ISSS) will contact you, via email, requesting that you complete the online J-1 request. This process will require that you upload supporting documentation, including your resume/CV, proof of $2050 per month to cover living expenses while you are in the United States, and a photocopy of your passport identification page.
Be sure to review Preparing for Travel and Welcome to Philadelphia information on GHP website, as early as possible: http://www.med.upenn.edu/globalhealth/intl_students.shtml#PreparingForTravel *If you do not qualify for a visa waiver (not from visa waiver country or staying in USA > 90 days) please allow 3-6 months to arrange visa
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VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS MEDICAL SCHOOL CERTIFICATION AND STUDENT ATTESTATION
International Medical School Official Certification

for completion by Dean/designated official of students 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 and will be returning to this institution to complete medical studies. This further certifies that the information provided on this application is correct, and that the student does have our permission to engage in research activities at the University of Pennsylvania Perelman School of Medicine. The student has completed the equivalent of a US bachelors degree (a minimum of four years of post-secondary school education). 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 students ever having engaged in criminal activity of any kind.
MEDICAL SCHOOL OFFICIAL: Last Name : Official Title: Medical School Name:
First Name: Email Address:
Location: (city/country) Yes No
Is instruction at your medical school in English?
(if English is not the principal language of instruction, students TOEFL exam results must be provided)
Signature of Medical School Official
Date
Student Attestation & Behavioral Agreement

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 at Penn, I understand that I remain a student in my home school I will respect the confidential nature of all medical records and personally identifiable information related to patients I 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 Perelman School of Medicine I shall respect all property belonging to the University of Pennsylvania and its affiliated institutions and I understand that will be responsible for the repair or replacement of any property damaged or destroyed by me I will be responsible for my own housing and transportation to and from the Perelman School of Medicine I understand that if I am unable to attend scheduled activities, I must notify the Perelman School of Medicine and my home school I agree to abide fully by the University of Pennsylvanias Code of Conduct (http://www.upenn.edu/osl/conduct.html) and Code of Academic Integrity (http://www.upenn.edu/osl/acadint.html), and abide by all laws and other relevant legal conditions surrounding the program I will conduct myself in accordance to the highest personal standards of character and integrity and not engage in any behavior that is deemed as inappropriate or unacceptable by the head of laboratory/internship supervisor or an authority of the Perelman School of Medicine or the University of Pennsylvania I will actively engage in the practice of good personal safety behaviors If in the opinion of the head of laboratory/internship supervisor or an authorized officer of the School, I am found to be in non-compliance of this agreement, I understand that my volunteer experience may be terminated immediately
_________________________________
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VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS MEDICAL SCHOOL CERTIFICATION AND STUDENT ATTESTATION
Signature of Medical Student
Date
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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 Global Health Programs 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 MMR Dose 1 ____/____/____ Dose 2 ____/____/____ Alternative regimen OR positive *titer verifying immunity MEASLES MUMPS RUBELLA Dose 1 ____/____/____ Dose 2 ____/____/____ Dose 1 ____/____/____ Dose 1 _____/____/____ OR OR OR *Titer quantity _________ *Titer quantity _________ *Titer quantity _________ Lab report attached Lab report attached Lab report attached Students
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 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: ____/____/____ **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_____________________________________________________________ Signature_______________________________________________________________ Phone #______________________________ Date_________________________________ Negative Positive ____/____/____ Negative Negative Positive Positive OR Date and result of QuantiFERON/IGRA blood test for TB infection ____/____/____
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Address________________________________________________________________________________________________________
ADULT CONSENT STATEMENT (age 21 or older)

I, ________________________________________________, understand and consent as follows:
Print First and Last Name
1. I have been offered a volunteer research opportunity within the Perelman School of Medicine for educational/training purposes. 2. I understand that laboratories are specialized environments in which chemicals, biological materials, and special instruments are often used, which can have the potential for creating hazardous conditions. I agree to follow supervision in order to reduce such risk. I am aware of the potential for such risk, and I agree to volunteer in a Perelman School of Medicine laboratory. 3. In the event of any emergency occurring during my volunteer experience, I grant permission to the University of Pennsylvania, its physicians, members of the faculty, agents and employees to provide such emergency care and treatment as in their judgment may be deemed necessary or advisable. I agree to cover the cost of such emergency care and treatment, if any. 4. I accept responsibility for providing any treatment or care I might require beyond emergency treatment. Signed: ____________________________________ Signed (witness):_________________________________ Date: ______________________________________ Date: _________________________________________
PARENTAL CONSENT STATEMENT FOR MINORS
(under age 21)
As the undersigned parent/guardian of ________________________________________________, I understand and consent as follows: Print Minor Students Full First and Last Name 1. My child has been offered a volunteer research opportunity within the Perelman School of Medicine for educational/training purposes. 2. I understand that laboratories are specialized environments in which chemicals, biological materials, and special instruments are often used, which can have the potential for creating hazardous conditions. I am aware of the potential for such risk, and I agree to my childs volunteering in a Perelman School of Medicine laboratory. 3. In the event of any emergency occurring during my childs volunteer experience, I grant permission to the University of Pennsylvania, its physicians, members of the faculty, agents and employees to provide such emergency care and treatment as in their judgment may be deemed necessary or advisable. I agree to cover the cost of such emergency care and treatment, if any. 4. I accept responsibility for providing any treatment or care my child might require beyond emergency treatment. Name of Parent/Guardian: (Please print full name): _________________________________________________ Signed: ____________________________________ Signed (witness):_________________________________
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Date: ______________________________________ Date: _________________________________________
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Intl Medical Student Applicationform Research 120712

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Intl Medical Student Applicationform Research 120712

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GLOBAL HEALTH PROGRAMS

(month/day/year) (month/day/year) (month/day/year)

Home Address (street, city, state, postal code, country)

Penn Medicine/ Global Health Programs / globhlth@mail.med.upenn.edu

GLOBAL HEALTH PROGRAMS

International Medical School Official Certification

First Name: Email Address:

Location: (city/country) Yes No

Is instruction at your medical school in English?

Signature of Medical School Official

Student Attestation & Behavioral Agreement

Penn Medicine/ Global Health Programs / globhlth@mail.med.upenn.edu

GLOBAL HEALTH PROGRAMS

Signature of Medical Student

Penn Medicine/ Global Health Programs / globhlth@mail.med.upenn.edu

GLOBAL HEALTH PROGRAMS

VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS IMMUNIZATION RECORD

Penn Medicine/ Global Health Programs / globhlth@mail.med.upenn.edu

GLOBAL HEALTH PROGRAMS

VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS IMMUNIZATION RECORD

ADULT CONSENT STATEMENT (age 21 or older)

PARENTAL CONSENT STATEMENT FOR MINORS

(under age 21)

Penn Medicine/ Global Health Programs / globhlth@mail.med.upenn.edu

GLOBAL HEALTH PROGRAMS

VISITING STUDENTS FROM INTERNATIONAL MEDICAL SCHOOLS IMMUNIZATION RECORD

Penn Medicine/ Global Health Programs / globhlth@mail.med.upenn.edu

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