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UL Medical Student Travel Proposal Form
The purpose of this form is to alert the SOM Global Education Office (GEO) and undergraduate International Center regarding plans for medical student travel prior to any student filing individual paperwork to the university or buying plane tickets or other non-refundable items. By seeking approval for the proposed trip, potential trip participants can know if extra forms need to be filled out or special permissions must be sought in order to obtain credit for the experience. This form should be filled out for any organized trip with medical student participation and should be submitted at least 3 months in advance of proposed trip (but more time is always better). If students are traveling as a group, only one form needs to be completed for the whole group.
Name of Submitter
Email of Submitter
Trip Name
Location, month and year.
Destination
Country and City / Region
What type of travel proposal is being submitted?
*
Group
Individual
Start Date of Proposed Trip
MM
/
DD
/
YYYY
End Date of Proposed Trip
MM
/
DD
/
YYYY
Partner / Host Organization
Are there any current CDC or State Department warnings regarding this country?
*
Yes
No
What is the Partner / Host Organizations UL vendor ID?
(note: partners must obtain a vendor number for funds to be deposited directly from any U of L account, including the student fundraising account)
List the Partner / Host Organization website address
Who is the main contact person at the organization or site?
(name and contact info)
Email geomed@louisville.edu the letter of invitation from the organization or site.
List the attending physicians traveling with the you or the group
List name, specialty and clinical department
List the students traveling with you or the group
List name and MS year
Are all of the proposed participants in good academic standing? If any student falls below good academic standing or are put on academic probation, it is the responsibility of the student to inform the Global Education Office.
Yes
No
Are there participants from another UL school such as Public Health or Nursing?
Yes
No
Are there professionals from another area of medicine such as Pharmacy?
Yes
No
Are participants seeking academic credit for this experience?
Yes
No
Will participants use this experience as part of their service-learning portfolio?
Yes
No
Are any of the attending physicians U of L faculty, fellows or upper level residents?
Yes
No
What is the "attending to student" ratio?
Example: 5 to 1
If no U of L SOM faculty are traveling with the group, but participants are seeking academic credit or service learning credit for the work, who is the U of L faculty (may be an adjunct) who will sign off on paperwork and review essays for service learning credit?
Name and email address
Proposed activities (clinics, surgeries, public health projects etc) in 2-3 sentences:
What measures will you take to ensure the safety of participants? (formal safety plan, satellite phone, guarded housing…)?
Proposed activities (clinics, surgeries, public health projects etc) in 2-3 sentences:
What pre-departure training (in addition to PDT required for the IDEP 911 course title) will participants undertake to prepare for the trip?
What measures will you take to ensure the safety of participants? (formal safety plan, satellite phone, guarded housing…)?
What vaccinations or medications are required to travel to your site (see CDC.gov)?
Who is the designated student to pick up and return the HIV exposure kit from the U of L travel medicine clinic?
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