Paul S. Lietman Global Health Travel Fellowship for Residents and Fellows

Application and Commitment Form

- Fall 2017 –

(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: Middle:
Citizenship / Citizenship: Select CitizenshipUnited StatesOther If “Other” please specify
VISA Type:
Local Address / Street:
City: State: Zip:
Contact Information / Email: Phone:

1.2 Rotation Related Information

Training Program / Department JHH JHBMC Other, spec.
Status / Resident Fellow Other, spec.
NPI
Employee Number / (associated with your payroll, not your JHED or badge ID)
Rotation Dates (approx.) / From: To: Number of weeks:
Rotation Location / City: Country:
Is this country considered a low- or middle-income country by the World Bank?
Global Health Pathways Program* / Are you in the Global Health Pathways Program?
If you are applying through the GHPP, please indicate your track: Select TrackTrack 1 (4 weeks)Track 2 (8 weeks)No track - not GHPP
Faculty Reference: (who will be submitting your letter of recommendation) / Name and Title:
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.

Country / Reason for travel / Year / Total Time


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 – do not copy 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 $5,000. Please note: 1) the sum of expenses in large categories should total the amount you are requesting; expenses beyond $5,000 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, though these numbers are subject to change and are not guaranteed.

Item / Source of Estimate / Amount
Transportation
Housing
Food
Other
Other
Total Request

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)ApprovedPendingDeniedOther
(SelectOne)ApprovedPendingDeniedOther
(SelectOne)ApprovedPendingDeniedOther


Part 5 - Commitments

Applicant:

4 
5 
5.1  Applicant agrees that if selected for this placement s/he will complete the reporting requirements listed above within one month of his/her return from the rotation. / Yes No
5.2  Applicant agrees that if selected for this placement s/he will present if possible on her/his experience at the next Global Health Day following the completion of their rotation provided that they are still in training at Hopkins. / Yes No
5.3  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
5.4  *GHPP applicant certifies to complete all Global Health Pathways Program specific requirements, in addition to CGH 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 () from:

o  Track 1: the country director (see webpage)

o  Track 2: the research supervisor

Send all application materials by the due date to:

Lietman Travel Fellowship Page 5 of 5 Email questions to Nina Martin |