AAP Section on Orthopaedics | Global Outreach Scholarship Trip Report Form
The final trip report form must be submitted within 30 days of the trip. Submit form to SOOr via Niccole Alexander at nalexander@aap.org
Name
*
First Name
Last Name
Email
example@example.com
Date of Trip (Start Date)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Trip (End Date)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Outreach
*
Surgical
Conference
Both
Other
Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Facility
*
Children's Hospital
Academic Medical Center
General Hospital
Clinic
Team Leader(s) | Mark n/a if not applicable
*
Rows
First Name
Last Name
Email
Phone Number
Team Leader Name #1
Team Leader Name #2
Team Leader Name #3
Team Leader Name #4
Sponsoring Organization
*
Rows
Organization Name
POC
Website
Email
Phone
Sponsoring Org #1
Sponsoring Org #2
Sponsoring Org #3
Sponsoring Org #4
Participants List (name, function, professional role) - Attach as Appendix A.
*
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Trip Summary ‐ highlights of trip, narrative or word attachment with images - Attach as Appendix B. Note: This narrative of your experience may be published in the "POSNA Resident Review" publication or on the SOOr website. It can also serve as the short presentation you will give before your peers at the Section on Orthopaedics educational program at the AAP National Conference and Exhibition.
*
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IMPORTANT: Please remember to bring the Photo Release Form with you prior to departure if you think you may be including pictures of families/patients as part of your report. This form can be obtained on the SOOr website. Attach as Appendix C, if needed.
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TRIP LOGISTICS
Names of other sponsoring organizations. Attach as Appendix D. (name, website, what was contribution ‐ either financial or in‐kind)
*
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What local programs (clubfoot, spine, etc.) were involved?
*
Total volunteers on the trip (number)
*
Total cost for entire trip (amount)
*
Individual member costs - Attach a copy of the airline and lodging receipts as Appendix E. The scholar will receive a check for $1,500 after the trip report plus the receipts have been submitted and approved. A W9 will be forwarded after the trip for the recipient to complete.
*
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CLINICAL DETAILS
Most common clinical diagnosis (list up to 5)
*
Rows
Diagnosis
Item #1
Item #2
Item #3
Item #4
Item #5
Total patients seen in clinic (number)
*
Total OR cases (number) | Provide case lists if appropriate, Appendix F.
*
Most common OR procedures (list up to 5)
*
Rows
Procedure
Item #1
Item #2
Item #3
Item #4
Item #5
List major complications (list all)
*
What equipment or supply issues/problems were there?
*
List greatest safety concerns (sterile supply, lack of blood bank, anesthesia … )
*
EDUCATION
Total local orthopaedic surgeons involved (number)
*
Total other local physicians involved (number)
*
US residents (number)
*
US fellows (number
*
Talks and speakers at training and teaching sessions
*
COMMENTS AND RECOMMENDATIONS
Would you return with this organization on future trips (yes, no)
*
Yes
No
What can be done to further involve local doctors?
*
What worked best?
*
What did not work?
*
Recommendation for future trips
Submit
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