Global Health Experience Forms/Instructions

GHErequiredformsOn 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

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

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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

 

  • due by Feb. 1
  • send as email attachment to globhlth@mail.med.upenn.edu
  • waived for Botswana clinical students placed via lottery and for Max Kade fellows

Student Health Service Pre-Travel Visit Form

 

  • Review SHS form ASAP with special attention to personal health conditions and high-risk clinical experiences (requiring a meeting with GHP before your SHS visit)
  • Email Sharon Robinson (msha@upenn.edu), to schedule SHS visit at least 3 months before travel – 6 months if Hepatitis A vaccine needed
  • Complete student section and bring form to SHS Visit
  • Submit with Registration Form to GHP, Richards B405, 4th floor

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.

Registration Form

 

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.

International SOS

 

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)

Evaluation Form

 

  • before emailing this as an attachment or providing hard copy to your mentor/ supervisor, be sure to complete everything you can
  • without this completed form, experience is not acknowledged and travel advance must be returned
  • waived for Botswana clinical students placed via lottery

Global Health Experience Report/ Questionnaire

 

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

Additional Forms if Planned GHE is CLINICAL

High-Risk Clinical Experiences

 

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.

Phlebotomy Practice Recording Form

 

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

Post Exposure Prophylaxis Info

 

Review before departure and keep information at hand, in the event of an incident

Additional Forms if Requesting Travel FUNDING from Global Health Programs

Request for Travel Funds - GHP

 

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

 

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.

C1 - Penn Travel Reimbursement

 

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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