Attestation Form

(Logistics Requirements)

All students approved for an International Clinical or Research Rotation are required to submit the following items no less than one month prior to departure:

General Registration form

Copy of your valid Passport and RT Flight arrangements

Signed copy of the RVU Waiver of Liability Form, found on the RVU website at

Contact information while overseas, where we can contact you, including where and with whom you are staying.

Licensed Health Care Provider name and their contact information; the person who may be contacted to complete a clinical evaluation on your performance.

Proof of Immunizations as required by for the country of travel. In addition to specific country requirements (i.e. Botswana requires Yellow Fever) regardless of location, all students traveling overseas must show proof of the following immunizations within the time frame shown:

  • Hepatitis A and Hepatitis B completed series or titers
  • Oral Typhoid (less than 5 years) or IM Typhoid (less than 2 years)
  • Tetanus Booster (less than 8 years)

*Contact Passport Health at for locations to get your immunizations.

Copy of Finger Stick (HIV Prevention) Protocol from the site you will be working at, or RVU’s Finger Stick Protocol found on the RVU website at

Proof of Medical Evacuation Insurance. Students should check their medical insurance carrier, as they may already be covered for this. Medical Evacuation Insurance can be purchased from a variety of websites; such as for that particular month.

Confirmation from the US State Department of your STEP Enrollment.

  • If necessary, signed Travel Warning Authorization Form, found on the RVU website at

After returning from the rotation, all students are required to complete and submit the following items:

International Rotation Clinical or Research Questionnaire with a log of all cases seen and procedures done, completed within 4 weeks after you return or prior to graduation, whichever comes sooner.

  • The questionnaire can be found on the RVU website at:

Copy of student evaluation by an Attending Physician on site

Copy of Negative TB Test, completed within 3 months after you return or prior to graduation, whichever comes sooner.

If you have any questions, please do not hesitate to contact Molly Hunsberger (), or Dr. Camille Bentley ().

I have read and understand the logistic requirements of this rotation and will comply with its requirements so I can be eligible to receive Clinical Education Rotation Credits for my time spent overseas.

Print Name:

Signature:

Date:

Return a signed copy of this form to Molly Hunsberger (POD B) or .

Keep a copy for your records.

Robin Durand

Robin Durand is a paralegal and college instructor in South Carolina. She received an associate's degree in paralegal studies from a technical college in South Carolina, and has more than 13 years' experience as a paralegal. She has been a freelance writer for over one year and enjoys writing articles relating to legal matters and house and home information.

Attestation Form

Revised 03/2017