2025 Nuvance Health Global Health Elective Application Form

Application for Nuvance Health Global Health Elective

Thank you for your interest in participating in a Global Health Elective organized by the Nuvance Health Global Health Program. Please take a few minutes to complete the application form provided below. There are four sections that you will need to complete. IMPORTANT: Prior to initiating this application, please make sure to have the following documents available and saved on your computer and ready to upload: 1) A color copy of your passport (photo page); 2) Your passport size photo; 3) A signed copy of the Nuvance Health Financial Policy form and Global Health Elective Liability form (you can download it below from this form); 4) Your current curriculum vitae; 5) A one-page motivation letter; explaining your interest in participating in the Global Health elective and the expectations that you have in regard to this program. Thank you!
Section 1. Personal Information
Full Name (as shown in passport)*

PrefixFirst NameMiddle NameLast Name
Gender*

MaleFemaleOtherPrefer not to answer
Date of Birth (as shown in passport)*

DayMonthYear
Citizenship*
Do you have a passport valid for international travel?*

YesNo
Passport expiration date*

DayMonthYear
Passport number*
Cell Phone Number*

Area CodePhone Number
Official University E-Mail address*

Confirmation EmailPlease do not include personal email addresses here (such as Gmail, Yahoo, etc.)
Personal E-Mail address (This address will be used only for one of three purposes - in case of an emergency during the elective, if we need to send you large size files, or when we need to contact you as an alumni of the program after you've graduated. For all other communication purposes we will be using your official University email address)*

Confirmation EmailPlease do not include institutional (University) email addresses here
Which Institution are you primarily affiliated with?*

American University of the CaribbeanRoss University School of MedicineUniversity of Vermont Larner College of MedicineNuvance Health (Connecticut)Nuvance Health (New York)
Please indicate your current medical training level at the Institution, indicated in item 11 (above)*

Medical Student - 1st yearMedical Student - 2nd yearMedical Student - 3rd yearMedical Student - 4th yearResident, Nuvance Health (Connecticut)Resident, Nuvance Health (New York)FellowFacultyOther
Please indicate the Department that you are affiliated with at the Institution indicated in item 1 (above)*
Please indicate the date on which you completed or expect to complete all your core rotations (Internal Medicine, Surgery, Obstetrics and Gynecology, Pediatrics, and Psychiatry)*

DayMonthYear
Do you speak another language other than English? Please select from the list below. If you speak more than one of these languages, please select the one you are most proficient at.*

I do not speak another languageFrenchGermanHindiPortugueseSpanishOther
Please indicate your level of proficiency in the language selected in item 13 (above)*

1 - Elementary Proficiency (Able to satisfy routine travel needs and minimum courtesy requirements)2 - Limited Working Proficiency (Able to satisfy routine social demands and limited work requirements)3 - Minimum Professional Proficiency (Able to speak the language with sufficient structural accuracy and vocabulary to participate effectively in most formal and informal conversations on practical, social, and professional topics)4 - Full Professional Proficiency (Able to use the language fluently and accurately on all levels pertinent to professional needs)5 - Native or Bilingual Proficiency (Equivalent to that of an educated native speaker)
Have you had past International or Global Health experience(s) abroad?*

YesNo
Please provide details regarding your past International or Global health experience(s). Include countries visited, dates, aim and purpose of travel, main learning points, etc.*
Section 2. Global Health Elective Information

In this section, you will be able to select the preferred dates for the global health elective and the order of preferences of the six global health elective sites that we have available (Dominican Republic, India, Thailand, Uganda, Vietnam, Zimbabwe). You will also be asked to specify the departments you are interested in undergoing your elective. Please note that placement in the department of your choice is not guaranteed.
Please select a 6-week-long block of dates for your Global Health Elective. The deadline for submission of all applications for all 2025 date blocks is July 15, 2024.*

Block 1 - 2025 January 6 - February 14, 2025Block 2 - 2025 February 17 - March 28, 2025Block 3 - 2025 March 31 - May 9, 2025Block 4 - 2025 May 12 - June 20, 2025Block 5 - 2025 June 23 - August 1, 2025Block 6 - 2025 August 4 - September 12, 2025Block 7 - 2025 September 15 - October 24, 2025Block 8 - 2025 October 27 - December 5, 2025
Please read carefully the information below. IMPORTANT: Applicants are encouraged to rank the countries of preference. However, the final decision on placement is based on the official travel advisory recommendations and site availability. Please note that although the program makes its best efforts to place applicants at the site of their top preference, this is not always possible, and applicants may be placed within any of these six sites. IMPORTANT: We would like to bring to your attention that the Ugandan parliament has recently passed a new law that targets individuals identifying as LGBTQ+. This law carries serious consequences, including lengthy imprisonment, significant fines, and the death penalty for LGBTQ+ people and those deemed to be "promoting LGBTQ+ propaganda." President Biden called the new law "a tragic violation" of human rights and is considering sanctions and a reevaluation of U.S. engagement with Uganda. Please take the time to educate yourselves about the situation in Uganda using official sources like the US State Department (here) for the most accurate and up-to-date information.*

I acknowledge that I have read and understood the aforementioned information.
Using the drag-and-drop feature, please re-order the list of the available Global Health Elective sites in the order of your preference (1st being the most wanted elective site and 6th being last in your preference ranking).*
Please select up to three clinical fields you are interested in for your Global Health elective.*

CardiologyCardiovascular SurgeryEar, Nose and ThroatEndocrinologyGastroenterologyGeneral SurgeryGeriatricsInfectious DiseasesIntensive CareInternal MedicineNephrologyNeurologyNeurosurgeryObstetrics and GynecologyOphthalmologyPediatric SurgeryPediatricsSurgical OncologyTrauma and OrthopedicsOther
Please indicate whether or not you wish you travel for the Global Health rotation with classmate(s) or colleague(s). Please note that consideration of conjoined placement within a rotation site will be given only to applicants, each of whom have mentioned each others’ names in their application.*

No, I am traveling aloneYes, I would like to travel with classmate(s) / colleague(s)
Please provide the names of classmate(s) / colleague(s) with whom you wish to travel together*
Please provide full name(s)
Section 3. Health Insurance Information and Emergency Contact Information
Please specify the company that provides your medical insurance*
Is this medical insurance coverage provided to you by the Institution that you are affiliated with (specified in item 11 above)?*

YesNo
Does your medical insurance policy cover travel medical expenses?*

YesNoNot sure
In case of emergency, please provide the name of a person we can contact*

PrefixFirst NameMiddle NameLast Name
Please identify your relationship to the person listed in above item as the emergency contact*

ParentSpousePartnerFriendOther
Please provide the address for your emergency contact person*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please provide a phone number for your emergency contact person*

Area CodePhone Number
Please provide an E-Mail address for your emergency contact person*

Confirmation Email
Section 3. Documents to sign

We kindly request that you download the Nuvance Health Financial Policy Form, Global Health Elective Liability Form, GH Competencies and Requirements Form, and Independent Travel Policy Form. It is essential that you carefully read through both documents, sign them, and then proceed to upload the signed forms in the designated section of this application form. Your attention to this matter is greatly appreciated.
Independent Travel Policy Form
Nuvance Health GH Competencies and Requirements
Global Health Elective Liability Form
Nuvance Health Financial Policy Form
Section 4. File Upload
Please upload a color scan of the front page of your passport (PDF or JPEG files are acceptable)*

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31. Please upload a Letter of Good Standing provided by the Institution that you are affiliated with (PDF or JPEG files are acceptable)

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Please upload a signed copy of the Nuvance Health Financial Policy Form, Global Health Elective Liability Form, GH Competencies and Requirements Form and Independent Travel Policy form (all forms should be merged into one PDF file)*

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Please upload a 1-page motivation letter, explaining your interest in participation in the Global Health elective and the expectations that your have in regard to this program (DOC, DOCX, PDF, or JPEG files are acceptable)*

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Please upload your most current Curriculum Vitae (CV) (DOC, DOCX, PDF, or JPEG files are acceptable)*

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Please attach a passport-size photo (PDF, JPEG files are acceptable).*

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Application for Nuvance Health Global Health Elective

Section 1. Personal Information

Section 2. Global Health Elective Information

Section 3. Health Insurance Information and Emergency Contact Information

Section 3. Documents to sign

Section 4. File Upload

Sign and Submit Application Form