Yes  No   

 

PLEASE NOTE: It is important that you complete all parts of the application.  If your application is incomplete or does not clearly show the experience and/or training required, your application may not be accepted.  If you have no information to enter in a section, please write N/A.

Name and AddressName (First, MI, Last)

Email

Age

You must have a USA passport 90 days or sooner before departure or hold a USA Student Visa or Green Card. If a country other than the USA, but living in the USA, do you have a valid Green Card or Student Visa Yes No

Traveling with a WVSOM Club? Which team or club? Traveling with someone else Yes No

SKYPE Name

Rotation Specialty

Mailing Address

Permanent Address

I am using a 3rd party company for my rotation

Statewide Campus Information

SWC Regional Assistant Dean

International Rotation Information

Companion's Name:

Rotation Company Website Traveling as a single? Yes No

Companion's Email

Phone #

WVSOM Center for International Medicine and Cultural Concerns Student International Rotation Application

page 1 of 4

City State Zip

City State Zip

Cell Phone

Rotation Country of Choice

Actual Rotation Dates: How many weeks do you want to stay

SWC Director Phone #

Date of Birth

Rotation Company Name: Contact Person Name Contact Person Email

Companion's relationship to you: Companion's Phone #

Travel Dates

1. Please tell us a bitabout yourself - List your strengths and weaknesses as you see them:

2. Areas of personalinterest (art, music, sports, etc):

3. How well do youtravel alone?

4. Do you have anyvolunteer experience? If yes, please give a brief description of your experience (s):

5. How well do youwork/travel with groups:

6. Do you have anyinternational volunteer experience? If yes, please describe:

7. Please write abrief description on what you feel you can bring to this rotation/mission?

8. What are yourexpectations for this trip?

9. Have you everbeen to the country for which you are applying? If yes, please explain under what circumstances and how that experience was for you. If no, please explain why you have chosen this location?

10. Do you have anyinternational living (2 months or longer) experience? If so, please describe.

11. Do yo have anyexperience (travel, living, and/or work related) with persons in developing nations?

12. How do yourelate to people of different ages?

13. How do yourelate to persons of different cultures?

14. Please give abrief description about your culture.

15. What is yourbiggest fear or concern about traveling to the country you have applied for and/or the program?

16. Are you marriedor in a long term relationship, or have significant others (parents, spouse, girl/boy friend, children, siblings, etc.) who may have concerns about your participation and travel with this program?

17. How well do youfollow directions, accept instructions and advice from others?

18. How well do youfollow rules?

19. How do you dealwith stress?

20. How do you keepemotionally, mentally, and physically centered?

21. Are you willing todo a job other than the one assigned (i.e., you are a physician but you are asked to cook dinner; assist with moving debris; assist with cleaning the compound)?

22. For personsapplying for a rotation in an extreme poverty area, how well you can cope in a hardship setting: i.e., very hot, humid, no running water to bathe, exposure to insects, possibly no electricity, sleeping in tents, limited food options?

***Please provide the email addresses of four (4) references as follows: Three (3) Professional References:

o One (1) must be from a recent preceptoro Two (2) from a current or recent Professor and/or recent employer (within the last three

(3) years) One(1) personal reference from a friend or peer (no family members).

Professional Reference Name and Email:

Professional Reference Name and Email:

Professional Reference Name and Email:

Personal Reference Name and Email:

Self-Reference: If you were to be your own reference, how would you rate yourself on the following scale?

Group Dynamics Patience =

Group skills =

Self-control under group pressure =

Common sense/good judgment =

Organizational skills =

On time =

Rapport with peers =

Communication Skills Ability to cope with emergencies =

Ability to work with persons whose intellectual/cultural perspectives differ from their own =

Sensitivity to others =

Problem solving abilities =

Rapport with persons of authority =

Is there any additional information you would like us to know?

1 Below Average 2 Could use improvement 3 Average 4 Above Average 5 Very Good 6 Outstanding 7 Exceptional 0 N/A or Unable to

answer

Personality Intellectual ability =

Tactfulness =

Maturity =

Self-motivation/taking initiative =

Emotional stamina =

Health/sturdiness =

Flexibility/open-mindedness =

Personable/friendly =

Ability to accept criticism =

STATEMENT OF UNDERSTANDING REGARDING INTERNATIONAL ELECTIVES

I, ________________________________________ OMSI/OMSIII/OMSIV, have read and understand Institutional Policy E-16 and agree to the following statements as outlined in the Procedures for Institutional Policy E-16:

1. Final approval for the requested elective rotation will not be granted if all requested materialsas outlined in the procedure are not submitted per procedure guidelines.

2. All expenses associated with this rotation are to be borne by the student, i.e. travel, travelinsurance, meals, board, and required or optional materials.

3. WVSOM liability insurance will not cover students on international rotations; therefore,students are responsible for their own professional liability insurance at levels required by thejurisdiction in which the rotation will take place. In addition all students must purchase travelinsurance that will cover all items related to travel. Travel insurance must be purchased beforeor at the same time as acquiring air tickets and other travel expenditures.

4. I understand that the full approval of the Associate Dean for Predoctoral Clinical Education andthe student’s Regional Assistant Dean are needed 90 days before international departure. Ifeither Dean feels a student is not fit emotionally, physically or professionally for the location thestudent has chosen, or the student has not completed the check-list, or the USA StateDepartment lists the host country as a danger for USA travelers, or you have not completed aprevious rotation, failed a rotation or COMLEX exam or you are found not in good professionalstanding, or for any other reason WVSOM may deem a concern about the student or the hostlocation, can be reason for denial of a recommendation for credit placement or removal from ahost site for any student.

Student’s Printed Name ______________________________________________________________

Student’s Signature ____________________________________________ Date ____________

Witness _________________________________________________________ Date ____________ (Present Preceptor or Regional Assistant Dean) Present rotation location ___________________________________________

Expectations of students on an international rotation

1. It is of the uppermost importance that you learn about the culture you will be working in, both before you depart and once you are there. Wikipedia is not a bad start for a cultural history lesson, but also check with CIMCC for recommended videos and reading list. Be sure you are aware of traditions and taboos so as not to embarrass yourself or finding yourself unwittingly in trouble or ostracized by your host community. Building trust is key to any physician’s relationship with their patient and hope for patient compliance.

2. Remember you are a student of osteopathic medicine. You are an Ambassador for Osteopathic Medicine and WVSOM, meaning it is your responsibility to share with your preceptor (in a polite and culturally sensitive manner) all you know and understand about OPP & OMT and how OMT can enhance the use of medication or even in some cases substitute for the use of costly medications (especially in developing nations where medicine is scarce and very costly to the patient). Be very aware as to how you present this information to your preceptor and the medical support staff, as well as the patient(s) you are working with, as not to insult them or infer that you are better than they are in regards to medical knowledge. The best way to do this is to prepare a PowerPoint slid show on your computer. Both Dr. Karen Steele and Dr. Zachery Comeaux have already prepared presentation you can use as resources (we will be happy to send you a copy) or create your own versions. This is especially important if you are doing a rotation in a country that does not fully recognize American Trained Osteopathic Physicians (ATOPS)

Requirements for completion and credit of an international rotation In-addition to requirements stated in your class year CLINICAL EDUCATION MANUAL, students participating in an international rotation must also complete the following and send to both your Regional Assistant Dean (RAD) and to CIMCC:

1. A written report (no less than 3000 words, size 11 or 12 font, 1.15 spaced) outlining an overview of your rotation experience. This narrative must include:

a. A description of what you experienced b. A description of what you learned c. How you presented OPP/OMT to the host community (give examples) d. What living conditions were like e. How was the preceptor to work for/study under

One of the easiest ways to approach this task is to keep a daily journal of the events that occur on rotation.

2. The above written report needs to be turned into CIMCC and your RAD no more than either 14-days after rotation, or if the rotation ends in May, then no less than 14-days before graduation.

3. An exit interview with CIMCC (this can be done via Skype, but preferred in person if possible) no more than 14-days after rotation, or if the rotation ends in May of your 4th year, then no less than 14-days before graduation. This interview will include questions about your OPP presentation.

I _____________________________________________________ , have read all of the above and understand the importance of meeting all of the above obligations as a requirement to receiving credit for an international rotation. Signed _________________________________________________ Date _______________ Return this signed statement via e-mail or fax: (304) 647-6258 Attn: Leah Stone, and keep a copy for yourself.

WVSOM INTERNATIONAL TRAVEL REGISTRATION FORM

Please select only one:

Name First ________________________________________ Middle _______________________________

Name Last ________________________________________ Preferred Name________________________

Day Phone _________________________________ Evening ______________________________

Cell _______________________________________ E-mail _______________________________

Current Mailing address (if different from home) _________________________________________________

City _______________________________________ State/Province ___________ Postal Code ____________

Country ______________________________

Permanent/Home address __________________________________________________________________

City _______________________________________ State/Province ___________ Postal Code ____________

Country ______________________________

Program country __________________________________________

Program dates (not travel dates) _____________________ Length of stay at host location ____________________

Travel Information Departing from which airport _______________________ Returning to which airport _____________________

If traveling to multiple countries please attach a travel/flight plan to this page Gender ___________ Age ____________ Birth Date ________________________ (mm/dd/yr)

Please check all that apply to your travel plans: ____ Traveling alone

____ I am traveling with someone (traveling companion’s name _____________________________________)

____ Traveling companion is also a WVSOM student

Arranged Travel: ___on your own, ___with WVSOM, ___with a travel agency (name of agency______________) Arranged Housing: ___on your own, ___through WVSOM/CIMCC, ___ other: _________________________ Valid passport: ___ Yes. Passport must not expire before 6 months after your return. ___ No. You must have a passport 3 months before your departure. Passport #______________________________________ Country of issue___________________________

Issue date___________________________ Exp. date______________________________

Please attach a photocopy of the ID page of your passport and an original wallet size or passport photo

Participating in Rotation _______, WVSOM Club trip _______, or Summer or Christmas break “Touch Hour” volunteer

program _______, Summer med course ________ (South Africa______ Malawi ______ Both _____)

Host Location or organization___________________________ Host Country ________________________

Planned travel departure date ________________ Return date _______________

HEALTH & EMERGENCY CONTACT FORM Name ________________________________________________________

Travel Dates: From_____________ To____________ Country traveling to: ___________________________

All of the following information is 100% confidential and bound by a code of ethics.

Age____________ Birth date__________________ Social Security #________________________________ If you answer yes to ANY health concern, please explain on the back of this page or attach additional pages.

Do you have any major health concerns like high blood pressure, diabetes, heart condition, seizures, asthma, depression, etc.?

Are you taking any prescription medications that you might need to have refilled if you lost them while traveling? If yes, please list:

Are you at present or have you been on any antidepressants, anxiety related, or psychotropic medication in the past 6 months? If yes, Please explain:

Have you had the following shots: ___Tetanus in the last 7 years), ___ Hepatitis A, ___ Hepatitis B

Are you a smoker ___No ___Yes? If yes, please be aware that all of our accommodations are non-smoking. Smoking is only permitted in designated areas.

Please list any dietary restrictions, food preferences, or food allergies: ______________________________

Please check the CDC for recommendations on prophylactic medication for your country of travel. Also please check the CDC for malaria information at http://wwwn.cdc.gov/travel/contentMalariaDrugsPublic.aspx and http://www.rocheusa.com/products/lariam/lariam_medguide.pdf. If you are only going to the Cape Town South Africa area, malaria medication is not necessary because this is a malaria free zone. In case of emergency please list contact persons in USA or home country:

1. Name_______________________________________ Relationship to you__________________________

Address______________________________________________ City_________________________________

State or Province____________________ Country_________________________ Postal Code_____________

E-mail address_____________________________________ Cell phone_______________________________

Phone day____________________________________ Phone night__________________________________

2. Name_______________________________________ Relationship to you__________________________

Address______________________________________________ City_________________________________

State or Province____________________ Country_________________________ Postal Code_____________

E-mail address_____________________________________ Cell phone_______________________________

Phone day____________________________________ Phone night__________________________________

Insurance Information: All WVSOM CIMCC participants must have health and hospitalization insurance that will cover them outside of their home country. Travel insurance is mandatory; it covers your cost in full if for health or other reasons you have to cancel your trip. It also covers all emergencies during the trip. You may purchase your own or it may be included in your participation fee. Name of policy_____________________________________________________________________________

Name of policyholder________________________________________________________________________

Policy #____________________________________________ Group #________________________________

ID #________________________________ Admission Approval phone #______________________________

WVSOM and its approved partners pledge to do their best to assure a safe travel experience, however in today’s world anything can happen. Therefore it is necessary for all participants and the parents of those participants under 18 years of age to read, understand, and sign witnessed by a Notary, the following waiver.

RELEASE AND WAIVER OF LIABILITY Please print name in full in large spaces. Please INITIAL in small spaces before each

“I” and last page MUST be notarized I, ____________________________________ (the “Participant”), release and forever discharge and hold harmless WVSOM and its approved partners and vendors (“WVSOM-apv”) and its successors and representatives, and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise or may hereafter arise from my participation in the CIMCC program or related WVSOM travel.

____I understand and acknowledge that this Release discharges WVSOM-apv from any liability or claim that I, the Participant, may have against WVSOM-apv, with respect to any bodily injury, personal injury, illness, death, or property damage or theft, that may result from my participation in the CIMCC program. I also understand that WVSOM-apv does not assume any responsibility for or obligation to provide financial assistance, legal assistance or other assistance, including but not limited to medical, health, or disability insurance, in the event of injury, illness, death, or property damage.

____I understand and accept that I, the Participant, am totally responsible for carrying and maintaining health, medical and/or disability, and liability insurance.

____I accept responsibility for and release and forever discharge WVSOM-apv from any claim whatsoever which may arise on account of any first-aid or emergency medical treatment, or other medical services, rendered in connection with an emergency during my time with the CIMCC program.

____I understand that traveling anywhere in the world has its risk and I accept full responsibility for myself, my actions, my health, and well-being while participating in the CIMCC program.

___ I have visited the Center for Disease Control (CDC) site-specific web-site and have read the health risk of travel to the country (ies) I will be visiting and I understand and take full responsibility for all related health risk.

____I understand and accept that if I am arrested and found guilty of breaking any laws in the USA or host country while participating in the CIMCC program, that I am fully responsible for myself and release WVSOM-apv of all responsibility, liability, or claim. I, __________________________________ assume ALL responsibility for my behavior, health, and well-being. Photographic Release ____I grant permission to be photographed, videotaped, and/or audio recorded and convey unto WVSOM/ CIMCC all rights, title, and interest in any and all photographic, video images, and/or audio recordings made by the WVSOM/CIMCC program or the media during my participation with the WVSOM/CIMCC program, including but not limited to royalties, proceeds, or other benefits derived from such photographs or recordings. WVSOM Code of Conduct WVSOM’s CIMCC international program means traveling to areas where social attitudes about dress, public behavior, and personal decorum may be different from that of the USA. We expect WVSOM/CIMCC program participants to behave with the utmost dignity and respect for themselves, the WVSOM/CIMCC program, other members of the project, and the communities that you are visiting.

Alcohol: This is a WVSOM-recognized event and all campus rules abide even off campus.

Drugs: ABSOLUTLY NO ILLEGAL DRUG USE; marijuana and all other street drugs even if legal in the host country are not viewed as legal in the USA or by WVSOM.

Weapons: ABSOLUTLY NO WEAPONS of any sort are allowed on any WVSOM/CIMCC program or projects.

Page 2 of 2 RELEASE AND WAIVER OF LIABILITY – signature page

WVSOM/CIMCC reserves the right to expel any member placing him/herself, any member of the group, or the CIMCC program at either personal or political risk or found breaking the code of conduct. WVSOM/CIMCC program also reserves the right to determine if a participant’s behavior is in the best interest of the project, and if deemed a detriment to the program, the WVSOM/CIMCC program representative reserves the right to expel said participant from the program. Any member asked to leave the program, for whatever reason, or any member wishing to leave early, for any reason, does so at his or her own expense; there are no refunds. In addition such person(s) will come before the VP of Student Affairs and the Dean of Students in accordance with WVSOM disciplinary policies upon his or her return to the WVSOM campus. ____I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of West Virginia, USA (home state of WVSOM) and __________________ (home state of the participant), and that this release shall be governed by and interpreted in accordance with such laws.

____I understand that I am fully responsible and legally liable for all my financial needs and expenses and any debts I may incur as an CIMCC Program Participant, all of which I will pay in full; including but not limited to, debts incurred in the host country, to WVSOM, other participants, persons, or institutions. Participant signature_______________________________________________ Date____________________ Notary___________________________________________________________ Date____________________

Address__________________________________ City________________ State/Provence______________

Country__________________________________ Term dates____________________________

Seal __________________