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Additional required documents
All of the instructions/requirements for individual travelers are in one place, which then links the
person to description of insurance benefits and exclusions, how to download a membership card, how
to register for the health insurance, links them to the three forms they need to fill out.
The document, which is called "PROCEDURES FOR TEMPLE UNIVERSITY STUDENTS TRAVELLING
INTERNATIONALLYON TEMPLE UNIVERSITY ORGANIZED, SANCTIONED OR FUNDED ACTIVITIES" is linked
online, https://tutr.temple.edu/Uploads/individual travel .pdf
Best,
Jacleen Mowrey I Associate Director I Education Abroad & Overseas Campuses Temple University I 200 Tuttleman Learning Center I 1809 N 13
th Street I Philadelphia, PA 19122
(P) 215.204.0720 I (F) 215.204.0729 I studyabroad.temple.edu
Documents Checklist
For Your Records
Before You Go:
� __ Pre-Travel Safety/Information Form
� __ Pre-Travel Authorization Form (Dean Signature)
� _ Passport Form
While You Are There:
� __ International Site Expectations & Validation Form (Site
Coordinator Signature)
� __ Activities Log
� __ International Site Coordinator Evaluation Completion
When You Come Back:
� Post-Travel Evaluation
� __ Global Health Programs Completion Form (Dean Signature)
Pre-Travel Safety/Information Form
Please return this completed form to Gina Ralph at [email protected] at least 4 weeks before your departure.
Name: ______________ Med School Year: (Circle one) 1 st 2nd 3rd 4th
Email: Phone: ------ ----------
International Phone or Other Contact Info: --------------------
Dates of Travel: Departure from US: (__/ __ / __ � Return to US: (__/ _ _ / __ �
Airline: ---------------- --- -------------
Flight Numbers Departure from US: --- --- - - --------------
Flight Numbers Return to US: ____________ ___________ _
Name of Site or Organization: _______ _ ____ ___________ _
Site Location: ------------------------ ------
Site Contact Person (Name & Title): ----------------- -----
Site Contact Phone number (Including country code): ____ _ __________ _
Site Contact Email Address: - ---- --------- - ----------
Do You Have All Required Vaccinations/Medications/Visas/Passport? _ _ _______ _
Have You Researched Safety Recommendations From The State Department?: _____ _
Expected Activities at Site: ________________________ _
Other Expected Travel Plans (Not at main site): ________ __ _ ______ _
Personal Emergency Contact 1
Name: ____ _ _ _ ______ __ Relationship: ____________ _
Home Phone: Work Phone:
Cell Phone: Email: -------------
--------- ------
Person al Emergency Contact 2
Name: _______________ Relationship: ___ __ _______ _
Home Phone: Work Phone:
Cell Phone: Email: -------------
----------- -----
Date Received: ---------
Pre-Travel Authorization Form
Please return this completed form to Gina Ralph at [email protected] at least 4 weeks before your departure.
I
Have Completed/Submitted My Pre-Travel Safety/Information Form, &
Have Been Made Aware Of The Safety Guidelines & Requirements For
Global/International Experiences, &
Promise To Represent Temple As A Medical Professional To The Best
Of My Ability As Stipulated In The Temple Honor Code, &
Will Comply With Electronic Documentation Expectations, &
Plan To Complete All Necessary Documents.
Printed Name Student Signature Date
Director For Global Medicine Signature Date
Expectations & Validation Form (Clinical)
Please review this with your site coordinator upon arrival so he/she is aware of Expectations for our Temple students.
At the end of the rotation, please have him/her sign the form to validate the competency-based expectations.
Please return this form to Gina Ralph at least 4 weeks after your return.
Expectations
Professionalism:
The student shows up on time, dresses professionally, is respectful of patients and health care
workers in an ethical and culturally sensitive manner. At least 18 work days of 8 hours per day
is the expected professional time commitment.
Patient Care:
The student provides compassionate care to promote patient health; gathers essential and
accurate information; makes informed decisions about diagnostics and therapeutics; counsels
patients/families; and creates patient management plans.
Medical Knowledge:
The student is able to create a differential diagnosis; demonstrate knowledge regarding
established practices and apply this to clinical practice.
Interpersonal Communication & Skills:
The student effectively communicates with patients/families/health care team; and establishes
therapeutic rapport with patients.
Practice-Based Learning & Improvement:
The student must investigate and evaluate their patient care practices; appraise and assimilate
scientific evidence; utilize information technology to support education; facilitate the learning of
others; and perform evidence-based care.
Systems-Based Practice:
The student can identify health care resources to provide optimal care; understand health care
delivery systems; and advocate for quality patient care.
Validation
Student Printed Name
Site Coordinator Signature Date
Expectations & Validation Form (Language)
Please review this with your site coordinator upon arrival so he/she is aware of Expectations for our Temple students.
At the end of the rotation, please have him/her sign the form to validate the competency-based expectations.
Please return this form to Gina Ralph at least 4 weeks after your return.
Expectations
Professionalism:
The student shows up on time, dresses professionally, and is respectful of educators and other
learners in an ethical and culturally sensitive manner. At least 18 work days of 8 hours per day is
the expected professional time commitment.
Patient Care:
If applicable, the student promotes patient health; gathers essential and accurate information; and
helps to counsel patients and families.
Medical Knowledge:
The student is able to demonstrate language proficiency, recall of learned information and
pertinent application of vocabulary, grammar, tense and pronunciation.
Interpersonal Communication & Skills:
The student effectively communicates with educators and other learners in a culturally sensitive
manner.
Practice-Based Learning & Improvement:
The student must investigate and evaluate their language skill practices; appraise and assimilate
new learning; utilize information technology to support education; and facilitate the learning of
others.
Systems-Based Practice:
The student can identify language resources to provide optimal proficiency.
Validation
Student Printed Name
Site Coordinator Signature Date
Activities Log (Clinical)
Please return this completed form to Gina Ralph within 4 weeks of your return to the U.S.
Patient Diagnoses Procedure/Language Learning Pearl
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Activities Log (Clinical)
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Patient Diagnoses Procedure/Language Learning Pearl
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Activities Log (Language)
Please return this completed form to Gina Ralph within 4 weeks of your return to the U.S.
Speaking To Who Vocab/Grammar/Tense Language Learning Pearl
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Post-Travel Evaluation
Please return this completed form to Gina Ralph within 4 weeks of your return to the U.S.
Name: ---------- -- -- -
Med School Year: (Circle one) pt 2nd 3 rd 4th
Name of Site: - -----------------------------
Site Location: ------------ - - ---- --- - - - - - - ---
Arrival at Site: L_/ _ _ / __ � Departure from Site: L_/ __ / __ �
Contact Person (Name & Title): _______________________ _
Site Contact Phone number (Including country code): _______________ _
Site Contact Email Address: ---------- - - - --- - - - ---- --
0 v era ll Rating of Experience (Circle one): (very poor) 0 2 3 4 5 (very good)
Setting(Circle one): Rural Urban Other: _____ _ ___________ _
Number of Beds: ____ Patients Seen Per Day: __ __ Hours Worked Per Day: ___ _
Ability to Interact with Doctors (Circle one): (very poor) 0 2 3 4 5 (very good)
Ability to Interact with Patients (Circle one): (very poor) 0
Were There Accommodations for You: Y / N
1 2 3 4 5 ( very good)
Cost for Experience (Circle one): <$500 I $500-$1000 I $1000-$1500 I $1500-$2000 I $2000-$3000 I >$3000
Any Security or Safety Concerns: _ _________ ____________ _
What Do You Wish You Knew Before Going On the Experience:
Were There Application Problems: _ _______________ _____ _
Positive Aspects of Experience: ____ _ __________________ _
Negative Aspects of Experience: _____ _ _ __________ ____ __
Any Added Advice for Someone Looking into this Experience: ___________ _
Date Received: ---------
Global Health Programs Completion Form
Please return this completed form to Gina Ralph ([email protected]) within 4 weeks of your return to the U.S to
receive credit for the elective.
� __ Pre-Travel Safety/Information Form
� Pre-Travel Authorization Form
� __ International Site Expectations & Validation Form
� __ Activities Log
� __ International Site Coordinator Evaluation Completion
� Post-Travel Evaluation
� __ Global Health Programs Completion Form
Printed Name Student Signature
Director For Global Medicine Signature
Date
Date
Office of Student Medical Education
3500 North Broad Street Philadelphia, PA 19140
INTERNATIONAL AWAY ROTATION STUDENT PERFORMANCE EVALUATION
Upon completion of an off-campus study experience, this evaluation form must be completed and signed by the COURSE
INSTRUCTOR before appropriate credit can be recorded on the official transcript of the Temple University Schoolof Medicine.
INSERT
PICTURE
RECOMMENDED GRADE
Student Name:---------------------------
Institution: Lewis Katz School of Medicine at Temple University
Dates of Rotation : From: _________ To=--------------
Course: ----------------------
Course Supervisor Name and Title: --------------------Please Print
Course Supervisor Signature:------------------------
D Honors D High Pass D Pass D Fail D Incomplete
ASSESSMENT OF CLINICAL AND EDUCATIONAL ATTRIBUTES
Check one:
Check one:
D Inpatient
D Resident
CONTACT TIME WITH STUDENT
D Ambulatory
D Faculty
D Inpatient and Ambulatory DNA
D 0-2 Hrs D 2-6 Hrs D 6-15 Hrs D 15-20 Hrs D 20+ Hrs
COMMENTS (Subjective evaluation comments are compiled from faculty and residents into a summative evaluation that may beused
in the student's letter of recommendation or Dean'sletter.)
Did you have an opportunity to meet with this trainee to discuss his/her performance? DYes D No
FORMS SHOULD BE EMAILED OR FAXED TO: Manish Garg, MD, FAAEM Director for Global Health
Lewis Katz School of Medicine at Temple University
Emai I: manish.garg@tuhs. temple. edu
or Clerkship, Senior Coordinator @ [email protected]
FOR OFFICE USE ONLY: Course Title: _________ _ Course No.: Block No.: _____ _
FINAL GRADE: ____________ _ DEAN'SSIGNATURE--------------------
Manish Garg, MD, FAAEM
lnterprofessional Collaboration
*Working with multidisciplinary healthcare members Took initiative to communicatewith and work with other
Unable toassess
Professionalism
Did not communicate or work well
with the team including other healthcare professionals
healthcare professionals to
improve patientcare
*Sensitivity, empathy and respect towards patients and colleaguesWas disrespectful to patients Was respectful in all interactions,
Consistently engaged and
communicated well with other
healthcare professionals and
coordinated care of their patients
Unabletoassess
and/or colleagues, and/or was
indifferent to other points ofview
or cultures
and was empathetic and sensitive
towards different cultures and
points ofview
Was a very respectful and
empathetic team member in all
circumstances, including
challenging situations
*Patient Care responsibility and work ethic
Unabletoassess
Was not reliable, did not take
patient careresponsibility
seriously
Was reliable and tookfi1/l
responsibility for their patients
Clearly demonstrated an understanding of the duty and responsibility of being a physician and went above and beyond for their patients
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