| *Name of Organization: |
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| *Location (city, country): |
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| Contact Person: |
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| Title of Contact: |
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| Address of Contact: |
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| Phone of Contact: |
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| Email of Contact: |
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| Dates of your attendance: |
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| Purpose of site institution (3-4 words): |
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| Is there a language requirement? If so, state language: |
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| Activities available (check all that apply): |
patient care
public/community health research
clinical research
basic science research
other:
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| Opportunities appropriate for (check all that apply): |
preclinical students
clinical students
other restrictions:
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| 1. Please describe your activities while abroad (eg, seeing patients, clinical research, public health project, etc.): |
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| 2. Please describe the range of activities available, in addition to yours: |
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| 3. Would you recommend this institution to other Penn medical students? Why? |
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| 4. What did you not like? |
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| 5. Is there an application process for this institution? How does one arrange a visit? Are there important dates to know about? |
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| 6. What costs were associated with the trip, other than transportation. Please include institutional fees, housing costs, food, etc... |
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| 7. Did you receive funding for this trip? If so, from whom and for how much? Please provide important information, such as contacts, application procedure, and due dates: |
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| 8. Would you agree to be contacted by other students interested in this site? If so, please give your name and contact information: |
| Name: |
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| Email: |
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| Phone: |
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