Global Health Experience Forms/Instructions
On this page you will find all of the forms, checklists, and information sheets you need to meet Global Health Programs/ Perelman School of Medicine requirements for a global health experience. If you are just getting started in the planning process, print out the Chronological Planning Checklist to assist you. To help you manage the forms, we are also providing you with a Table of Required Forms that can be downloaded and printed for your use. Please note that most of these forms have sections that can and must be filled electronically before attaching as email documents and/or printing out, as instructed.
Pre-Travel
- Chronological Planning Checklist
- Table of Required Forms
- Global Health Experience Planning Form (this form is due by February 1 of the travel year)
- Global Activities Registry (there is no GHP form for this - register and submit screenshot that includes flight info)
- Registration (required for all students, regardless of funding status or length of travel)
- Student Health Service Pre-Travel Visit (consult WHO data from 2010 to determine need for TB screening)
- Video Documentation Form (required for students with clinical experiences in low-resource areas)
- Clinical Plan Agreement (required for students with clinical experiences other than IHS and BUP with potential for exposure to blood and/or other body fluids)
- International SOS -- Emergency Insurance Provided by Penn
- Phlebotomy Practice Recording Form (only for MS3/4 students with relevant clinical experiences)
- Request for Travel Funds -- GHP
- C7 - Penn Travel Advance
- C1 - Penn Travel Reimbursement
- Botswana Planning Checklist
- Post-Exposure Prophylaxis Instructions (for clinical experiences, review before and carry during travel)
During Travel
- Evaluation (requirement for all students with global health experiences; only exception: Botswana clinical elective)
- Procedures Log (for students in high-risk clinical assignments in Botswana)
- Procedures Log (for students in high-risk clinical assignments in non-Botswana locations)
- Report a Blood or Body Fluids Exposure Incident -- TBA
After Travel
- Global Health Experience Report/Questionnaire (requirement for all students)
Table of Required Forms
The table below explains which forms are required under various circumstances and at which point in the global health experience process. When saving forms electronically before attaching in email, please save as "[your name] [form title]" e.g.: "John Doe GH Exp Reg."To use the table below as a checklist, you may wish to download and print.
Color key:
- No fill indicates form is required 6 weeks before departure
- Blue fill indicates form is required before all other paperwork
- Green fill indicates form is required within one week of return
Forms for ALL Students Pursuing Global Health Experience (GHE) |
Planning Form |
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Student Health Service Pre-Travel Visit Form |
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Global Activities Registry |
Enter your travel plans in Penn's Global Activities Registry, and print a screenshot that includes your flight arrangements to submit along with your registration form. |
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Registration Form |
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Note that this form has an extensive checklist. When completed, send as email attachment to globhlth@mail.med.upenn.edu AND submit signed hard copy to GHP, Richards B405, 4th floor; GHP must receive before travel advance can be processed; at least 6 weeks before travel; be sure to include official correspondence from host/mentor, indicating specific dates of commitment and scope of activity. |
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International SOS |
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No submission at Penn; complete records online; enter emergency phone #s in cell phone; print out membership information and carry at all times (emergency insurance provided free for all students traveling for Penn-related related activities) |
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Evaluation Form |
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Global Health Experience Report/ Questionnaire |
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without this completed form, experience is not acknowledged and travel advance must be returned; submit completed form via email attachment* to globhlth@mail.med.upenn.edu |
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Additional Forms if Planned GHE is CLINICAL |
High-Risk Clinical Experiences |
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High-risk clinical experiences (potential exposure to blood/body fluids) other than Botswana-UPenn medicine electives arranged via GHP lottery, require a meeting with GHP to obtain pre-registration approval. No support is available without pre-approval. GHP meeting must take place before SHS visit. |
Clinical Experiences in Low-Resource Areas |
Students who plan clinical electives in Botswana or other low-resource areas must view videos and submit documentation form. |
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Phlebotomy Practice Recording Form |
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required only for MS3/4 students with clinical experiences that will include procedures in low-resource areas; form includes instructions on how to set up practice session |
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Post Exposure Prophylaxis Info |
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Review before departure and keep information at hand, in the event of an incident |
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Additional Forms if Requesting Travel FUNDING from Global Health Programs |
Request for Travel Funds - GHP |
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Send as email attachment to globhlth@mail.med.upenn.edu AND submit signed hard copy to GHP, Richards B405, 4th floor, between 6 and 12 weeks before travel. If you do not submit all required paperwork at least 6 weeks before travel, funding may be denied; travel advances must be reconciled upon your return, with original boarding passes and receipts. |
C7 - Penn Travel Advance |
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Send as email attachment only, to globhlth@mail.med.upenn.edu between 6 and 12 weeks before travel; fill in your Penn ID number and all payee information; the referenced Statement of Business Connection and Advance Justification C-7A will be provided by Financial Operations (FO). You will be directed to FO in 417 Anat-Chem by GHP after all Travel Advance paperwork is received. . If you do not submit all required paperwork at least 6 weeks before travel, funding may be denied; travel advances must be reconciled upon your return, with original boarding passes and receipts. |
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C1 - Penn Travel Reimbursement |
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Send as email attachment only, to globhlth@mail.med.upenn.edu between 6 and 12 weeks before travel; complete only section highlighted in blue. If you do not submit all required paperwork at least 6 weeks before travel, funding may be denied; travel advances must be reconciled upon your return, with original boarding passes and receipts |
Last updated: March 27, 2013
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