MSM Office of Global Health Equity

2019 Global Health Learner Experience Application

Deadline: December 2, 2019 by 5:00 p.m. EST

Applicant Information

I confirm that I have read the eligibility requirements for this funding opportunity. *

Yes

No

First Name *

Last Name *

Middle Initial *

Date of Birth *

MSM ID # *

Passport # *

Institution Name *

Are you a *

If you are a student, please select your current academic classification:

If you are a MSM student, please select your program:

Overall GPA:

If you are a faculty or staff member, please indicate your department and program:

If you are a resident, please indicate your department and year:

Contact Information

Mailing Address (Street, City, State, and Zip) *

Email address *

Phone Number *

Demographic Snapshot

Are you a U.S. Citizen?

Yes

No

Are you a permanent resident?

Yes

No

Gender *

Racial/Ethnic Background *

Please share the languages that you speak and the level of fluency. Click the plus sign to add additional languages.

+-

Interests

Please rank your interests areas (1-6) *

	Infectious Disease
	Chronic Disease
	Global Mental Health (e.g. PTSD)
	Clinical Research
	Clinical Practice
	Service
	Other

This experience will fulfill the requirements of (check all that apply) *

In what countries have you had previous learning experiences in? *

Required Materials

Summary of proposed learning experience project (500 words maximum): *

0/500 words

Please select the impact country of interest * 🛈

Please upload your complete proposal in Microsoft Word or PDF format. It should be succinct and must not exceed 6, single-spaced pages using 11 or 12-point font (preferably Times New Roman or Calibri). This should include the specific purpose and objective(s) of the proposed project. If human subjects research is involved, it must be approved by MSM IRB. You must also include an evaluation plan with specific aims or objectives and desired outcomes as well as how outcomes will be assessed. Proposals are due along with the submission of this application by December 2, 2019 at 5:00 p.m. EST. *

Proposed Time Period of Experience (Month, Date, Year - Month, Date, Year) * 🛈

Mentor Information

Do you have a mentor? *

Yes

No

First Name

Last Name

Email Address

Phone Number

Recommendation Contact Info

Please provide the contact information of two recommenders:

First Name *

Last Name *

Email Address *

Phone Number *

Upload Recommendation Letter 1

First Name *

Last Name *

Email Address *

Phone Number *

Upload Recommendation Letter 2

Estimated Experience Budget (max $5,000).

Lodging *

Air Transportation (Round Trip, Economy) *

Food *

In-Country Transportation *

Passport/Visa Fees *

Travel Insurance *

Immunization Fees *

Other Cost

Please upload a narrative justification for each part of the budget.

Electronic Signature

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for withdrawal from the applicant pool or return of the award. *

clear

Application Submission Date * +

Contact Us

MOREHOUSE SCHOOL OF MEDICINE

OFFICE OF GLOBAL HEALTH EQUITY

B352 HUGH GLOSTER

720 WESTVIEW DR SW

ATLANTA, GA 30310

Email: globalhealthequity@msm.edu

Website: www.msm.edu/globalhealth