Boston University School of Medicine

ADD Form for Global Health Elective
for Fourth-Year Medical Students

DIRECTIONS TO STUDENT:1)Complete thisformto add a GH elective to your schedule. When complete, send the formelectronicallyto Ana Bediako: . 2) Print, sign, and deliver the (paper) liability form to Ana in A-302; this form must be submitted for your elective to receive final approval.

Student &Emergency Contact Information

Student Name: / Class of: / E-mail:
Emergency Contact:[In the event of an emergency while you are abroad, provide a person for BUSM to contact.]
Name: / Telephone:
Relationship to you: / E-mail:

Understanding Your Responsibilities

Check here to indicate you have read and understandyourresponsibilities (click link to read full list) that must be completed to undertake a GH elective regardless of funding (i.e., receipt of BUSM travel grant).
Check here to indicate that you understand you are required to attend a pre-departure meeting with Dr. Sarfaty before the start of your elective. Check with Ana Bediako if you are not given a date/time for this meeting.

Course Information

Course Name:
[e.g.: Infectious Disease in India; Spanish Immersion in Ecuador]
Is this an inside or outside elective? Inside* Outside
[* An inside elective is one with an established affiliation with BUSM.]
  • If this is an inside elective, Ana will approve elective and send ADD form to the Registrar. No further action is needed.
  • If this is an outside elective, you are required to meet with Dr. Sarfaty to obtain approval. Once Dr. Sarfaty approves the elective, she will give the go-ahead to Ana to send ADD form to the registrar.

Block(s) of elective: / Start date: m/d/yy / End date: m/d/yy

Evaluator Information

[The physician you list below will complete the evaluation form (assign a grade) for your elective.]

Evaluator name: / Evaluator title:
Organization:
Address:
Phone: / E-mail:

------INTERNAL USE ONLY------

This elective was approved by Suzanne Sarfaty, M.D., Director of Global Health Programs, BUSM.

The ADD form was sent to the BUSM Registrar on .