Preliminary Application

Applicant's Primary Contact

NOTE: The name and information provided for the institution's primary contact will be used by ACIHE for communicating with the applicant institution. Postal deliveries, shipments, telephone calls, e-mail and fax transmissions will be directed to the individual identified as the Primary Contact using the contact information provided below.
Name

First NameLast Name
Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Email
example@example.com
Phone Number
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.

SECTION 1: Institutional Setting and Governance
a. In one phrase what is the mission statement of your institution's global health education program:
b. Describe the strategic plan to meet the programs mission statement.
Attach the educational institution's process of selecting the chief official and faculty of the international health care education program.*

*Label documentation "IS-2 Leadership Selection"
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c. Attach a Curriculum Vitae for the chief official and key faculty of the international health care education program. Please underline or highlight all aspects of the document that represents how each individual has the education and experience to provide leadership in international health care education. *

*Label document "IS-3 Leadership Qualifications"
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d. Attach an organizational chart that shows the organizational structure and staff reporting relationships for the international health care education in relation to the parent institution, where applicable. *

*Label document "IS-4 Organizational Structure"
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SECTION 2: Students
How many students are accepted into the program each year?
How many students are in the entire program during a calendar year?
c. List strategies used to promote diversity of students in the program:
SECTION 3: Educational Objectives
a. State the expected outcomes of the international health care education program in terms of changes in learner competencies:
b. Comment on the role that expected changes in competencies will have in educational planning, learner assessment, and program evaluation:
c. Describe the process and methods that will be used to assess learner attainment of the expected changes in competencies:
d. Briefly describe how the international health care education program expected changes in competence are made available to all participants, to the faculty, and to others with direct responsibilities for education and assessment:

SECTION 4: Curricular Content
a. Describe the types/formats of educational activities that support the core content areas:
b. List the core content areas of the international health care education program, demonstrating inclusion of those areas required by ACIHE:
c. Document how scientific research within the international health care education program conforms to the generally accepted standards of experimental design, data collection and analysis:
Does your program provide areas of specialization or electives? If so, please describe the specific knowledge, skills, and values of the specialization/elective:
Does an institutional policy on scientific research exist?

YesNo

SECTION 5: Service - Learning Content
a. Describe how service-learning sites and faculty are selected:
b. Describe the policies and plans for service-learning site contingencies for the following: transportation, accommodations, communication, safety, and emergency health and evacuation:
SECTION 6: Learner Evaluation
a. Attach an evaluation form that is used to track learner progress towards the expected changes in competencies.

Label document "Learner Evaluation Form"
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c. Describe how assurance is made that students have continuous, qualified supervision and do not engage in activities for which they are not trained and not supervised:

SECTION 7: Program Evaluation and Progress
a. Describe how the program will collect and analyze outcome data that evaluates the extent to which the international health program’s educational objectives are being met:
b. Describe how learners will be incorporated into the participation in the evaluation of program and faculty effectiveness:

ACIHE Initial Application