Year in School
at the time that you traveled on your global health experience
Summer between FOM1 & FOM2
2nd Year (FOM2)
3rd Year (CCE)
4th Year (AS)
Select Year in School
Year of Graduation
Elective Advisor Name
Advisor UMMS Department
Biochemistry & Molecular Pharmacology
Family Medicine & Community Health
Microbiology & Physiology Systems
Obstetrics & Gynecology
Orthopedics & Physical Rehabilitation
Program in Molecular Medicine
Quantitative Health Sciences
Select Advisor UMMS Department
Country to which you traveled
People's Republic of China
Other - please specify
(select the country in which you spent most of your time)
education or service
to which you traveled
Australia | Oceania
Central America | Caribbean
other - please specify
Month(s) and year of travel
eg, rural clinic, university hospital
Please list the
person(s) and or organization(s)
you contacted to set up this global health experience.
Primary focus of this global health experience
Language | cultural immersion
Public health | community service
If you selected
above, in which
did you gain experience during this global health experience
(check all that apply)
Hematology | Oncology
Hospice Care | Palliative Care
other (please specify below)
Other Clinical Field
(eg, language or clinical proficiencies)
Host Institution Supervisor
Name, title, position
Telephone and Email
Trip Expenses | Approximate Cost of Trip | Overall Rating
In the space below, please give a breakdown of the estimated costs of the different parts of your travel (e.g., $1,000 for airfare, $200 for housing in a university dorm room, $300 for food, $200 for in-country travel related to my study/work/research, $2
cost of trip
In the space below, provide the total of the different costs that you described above. Do not include any costs for recreation or entertainment.
List any sources of funding (and approximate amounts) that you received for this global health experience. (eg, $1000 from the Godkin Fellowship)
of this global health experience
of this global health experience (optional)
Health Measures | Site & Living Conditions | Packing & Preparation
Necessary Health Measures
Describe any necessary health measures prior to, during and after experience (eg, visitors entering this country are required to carry vaccination history, student should consider PPD skin test 1-3 months after returning from this country).
Packing and preparation
Describe any tips regarding packing and preparation that might be helpful for future students who travel to the same global health experience that you did.
positives and negatives
Describe any positives and negatives about the location and Host Institution where you did this global health experience.
positives and negatives
Describe any positives and negatives about the living conditions where you did this global health experience.
to students and residents
Summary | Reflection
Write a brief paragraph summarizing the degree to which your global health experience met your learning objectives and contributed to your medical education and career aspirations.
Reflect on educational and cultural experience
Reflection about the global health experience: Write 1 or 2 brief paragraphs describing what you learned about the country and culture that you visited. (Topics that you may discuss in these 1 or 2 paragraphs: lifestyle and living conditions, migration of immigrants to the US, religious and cultural beliefs and practices, health beliefs or practices, diseases or health conditions, health care systems, immigrants from this country who now are living in the US).
Reflect on personal impact
Reflection about the impact of the global health experience on you: Write 1 or 2 paragraphs regarding: (a) what you learned about yourself or your own country / culture, (b) the impact that the experience had on you, and/or (c) what you learned from this experience.