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GO Health App 2012

GO Health App 2012

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Published by Sabrina Bonaparte

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Published by: Sabrina Bonaparte on Feb 09, 2012
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January 27, 2012 Dear Applicant: Thank you for your interest in applying for a GO Health Fellowship.

The purpose of the GO Health Fellowship is to provide financial assistance to a graduate student, professional student, or medical resident at the University of Washington so that they may gain valuable international fieldwork experience in global health. The funds have been generously provided by donors committed to the education of global health professionals from diverse disciplinary backgrounds. The Fellowship of up to $4,000 (USD) can be used to support travel costs, including room and board, travel health preparation, travel insurance and/or supplies for a particular global health project. The GO Health Fellowship cannot be used to cover tuition costs, school supplies, conference attendance or other non-project related expenses. Funds can be used for experiences taking place anytime from summer quarter 2012 up to, and including spring quarter 2013. Applicants will be selected based on the following considerations: a) the strength of the project or experience proposal, b) the applicant¶s record of academic excellence, c) evidence of promise and commitment to a career in global health, and d) demonstrated financial need. Fellowship recipients must meet all program deadlines and program requirements, including attendance at a pre-departure orientation. If a student is awarded and accepts the Fellowship, they must immediately withdraw their applications to other UW fellowship or funded programs. Complete applications are due to Daren Wade, Director, Global Health Resource Center at the University of Washington, dwade@uw.edu by midnight, Wednesday, March 14, 2012. Eligibility criteria: 1) Graduate students or professional trainees enrolled in a full-time University of Washington degree program 2) Medical residents enrolled in a University of Washington residency program 3) Good academic standing 4) Demonstrated financial need (details in application process instructions) 5) Not currently receiving another award or fellowship for the same time period or for the same program or fieldwork experience 6) Participation in a global health-related program or fieldwork experience in an international, resource limited setting relevant to the student¶s/trainee¶s career goals 7) Minimum duration of six weeks abroad 8) The project or experience must be at a UW-affiliated international entity (eg. NGO, university, Ministry of Health or other research institution, etc.)

Application Process: By February 15, 2012 submit a one page Letter of Intent that includes the following elements: a) Your name; b) degree program or residency program; c) country in which you¶d conduct your project or experience; d) approximate dates of travel; and e) area of focus in global health for your project or experience (examples: ³Maternal and Child Health´, ³Clinical Medicine´, ³Human Rights´, ³Nutrition´, ³Water and Sanitation´). This letter of intent is NOT required but is strongly encouraged because it helps us to assemble a highly qualified panel of experts to review your application. Send to dwade@uw.edu with subject line: Letter of Intent: Go Health 2012. By March 14, 2012: submit the following three items: 1) Completed GO Health Fellowship application (sections A-E) A) Demographic information: Name, student ID #, address, phone, email, school, degree/residency program, year in program, relevant experience. B) Project/Experience proposal: (1-2 pages, double space, 12pt font) Outline of activity for project/experience, including identification of the site, partner, host faculty, and UW mentor faculty involved y Description of project/experience¶s relation to career goals and future plans C) Proposed budget: list expenses for travel, travel health, insurance, housing, food, and project costs. D) Letter of support from UW faculty mentor for project/experience outlining relationship and applicant¶s promise and commitment to a career in global health E) Signed statement of support from international host site supervisor or mentor for project or experience 2) Copy of unofficial UW transcript or, if you are a medical resident, a letter of good standing from your residency office. 3) Demonstration of financial need: a. U.S. students at the University of Washington need to complete the online Free Application for Federal Student Aid: http://www.fafsa.ed.gov/ b. International students at the University of Washington should contact Daren Wade, dwade@uw.edu in order to complete a form from the Office of Student Financial Aid by the application deadline. c. Medical residents: Submit a statement of need (1 page or less) that includes the amount of your monthly resident stipend and detailed financial information documenting your statement of need. A faculty committee will review your application and select candidates for interviews that will take place the first two weeks of April. Candidates will be informed of the committee¶s decision, shortly thereafter. If selected, a required pre-departure orientation will take place all-day on May 5, 2012.

A. DEMOGRAPHIC INFORMATION: Name of Applicant: _____________________________________ Student ID# or Employee ID#:_____________________________ Address: _____________________________________________ _____________________________________________________ Phone: _______________________________________________ Email: _______________________________________________ UW School and Department: ______________________________ Degree or Medical Residency Program:______________________ Anticipated Month and Year of Graduation or Completion of Residency: ______________________________________ Date of Birth:____________________________________ Citizenship: ______________________________________ Gender: ____________________________________ Race/Ethnicity: ____________________________________________ Language fluency: __________________________________________ Previous international work experience (location, duration & nature): ___________________________________________________________________ ___________________________________________________________________ Country where you propose to travel for this fellowship:_______________________ Approximate dates of travel: _____________________________________________ Area of Focus in Global Health for your project or experience (examples: ³Maternal and Child Health´, ³Clinical Medicine´, ³Human Rights´, ³Nutrition´, ³Water and Sanitation´): ____________________________________________________________________________

B. Please complete a 1-2 page project or experience proposal outlining: 1) Description of the project or experience

a. Background and rationale b. Key question(s) or issue(s) addressed by project or experience c. Proposed methods, approach and/or activities d. Anticipated outcome(s) or product(s) 2) Significance and potential benefit to host site 3) Applicability to your graduate or professional study here at the UW 4) Future plans in the field of global health

C. BUDGET PROPOSAL Please list your proposed travel and project related expenses up to $4,000 (USD). Name: Host Organization/Country: Expected dates at Host Organization/Country: Item Health Appointments and Insurance Health Screening fee Travel Health Clinic Consult fee US Health Insurance HTH Travel Health Insurance Major Expenses including immunizations, travel, room and board Vaccinations Malaria Prophylaxis and other travel medications Post-Exp. Prophylaxis (HIV) (clinical experience) NIOSH N-95 Respirator (if clinical experience) Airfare Visa Airport fees/Departure Tax Taxi/Bus/Rail Housing Food Phone Please list other items that will be > $50 USD value Project Supplies: Project Supplies: Other: Other: TOTAL COST Cost

D. Statement of Support: International Host Organization On-Site Supervisor or Mentor *applicant completes this information and submits the form to their on-site host supervisor Applicant Name:________________________________________________ University of Washington mentor:__________________________________ Time period applicant will spend in country for the project or experience: (Month/Day/Year) ____________to______________ ________________________________________________________________________ International Host Organization supervisor completes the information below:
Host Organization/University: Country location: City/Town

Administrative Contact Person (name):


E-mail/Phone Contact

Professional Supervisor or Mentor (name):


E-mail/Phone Contact

Months/Years you have known the University of Washington faculty mentor_________ Months/Years you have known the Applicant: ___________ The applicant has applied for funds through the Department of Global Health¶s GO Health Fellowship to spend at least 6 weeks with you and your organization, completing a project or experience related to their academic interests in the field of global health My signature on this form confirms my commitment to provide supervision and mentorship for the above named student for her/his work with us associated with the GO Health Fellowship. Please briefly describe your mentorship role and indicate the frequency with which you will meet with the applicant during their project or experience with you. Signature: Date:

E. Statement of Commitment: University of Washington Faculty Mentor Applicant Name:__________________________________________ University of Washington mentor:____________________________ The applicant has applied for funds through the Department of Global Health¶s GO Health Fellowship to spend at least 6 weeks with you and your colleague(s) abroad, completing a project or experience related to their academic interests in the field of global health In order to receive the GO Health Fellowship, students need to demonstrate a commitment by you to provide academic mentorship and supervision while the student is in-country working with the host organization supervisor and colleagues. The University of Washington faculty mentor should provide guidance to connect the applicant¶s activities to their academic program and career goals.

Faculty Mentor Name

UW School and Department





Months/Years You Have Known the Applicant: __________________ Relationship to International Host Organization/Mentor: ________________ Months/Years Working with the International Host Organization: _______________ Attach a Statement of Support letter: In 1 page, please outline details of the project or experience that you have discussed with the student and your role as their mentor for the project or experience. Please also provide your assessment of the applicant for work abroad and the applicant¶s academic ability, cultural competence, flexibility, openness, independence and promise to the field of global health.

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