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  • Example: 05/15/2019
    MM slash DD slash YYYY
  • If you are a faculty member that is interested in coverage for your spouse and/or children traveling with you, please include the name and date of birth of each additional person in the comments section at the bottom of this form.
  • e.g. 2010, 2013, 2014, etc. Please put n/a if you are a faculty member.
  • Enter the country of your destination, not your home country
  • Enter the city or region of your destination, not your home city.
  • Course Coverage

  • "Course" means the official organized experience (including direct travel to and from the course), regardless of whether you're getting academic credit for the experience. These dates should encompass everything that is not personal or extra tourist travel.
    MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Course Information

  • For instance "GLBE 401"
  • Program Contact Information

    Please enter the name, phone number, and email address of a contact (supervising physician or program contact preferred) located in the country you will be visiting. DO NOT, again, DO NOT LIST the student leader or the faculty advisor for your UNC student group (HHA, PPS, S2S). You may only list a UNC contact here if you are going to Malawi or another UNC site with full-time, in-country UNC faculty/staff. Otherwise, a host-site contact is required such as the in-country preceptor (clinical site), the principal investigator (research elective), or host-site administrator.
  • DO NOT LIST the student leader or the faculty advisor for your UNC student group (HHA, PPS). You may only list a UNC contact here if you are going to Malawi or another UNC site with full-time, in-country UNC faculty/staff.
  • DO NOT LIST the phone number of a student leader or the faculty advisor for your UNC student group (HHA, PPS). Please list an in-country phone number. You may only list a UNC phone number here if you are going to Malawi or another UNC site with full-time, in-country UNC faculty/staff.
  • DO NOT LIST the email address of a student leader or the faculty advisor for your UNC student group (HHA, PPS). You may only list a UNC email here if you are going to Malawi or another UNC site with full-time, in-country UNC faculty/staff.
  • For Example: Himalayan Health Exchange, Proyecto Puentes de Salud, UNC Project Malawi, Child Family Health International. If your experience is not with an established program, you must provide the name of the host organization, clinic, hospital, or other description here.
  • Is your medical student experience taking place at an official UNC global flagship site or an approved partner site? Only options include: HHA, PPS, UNC Malawi; UNC Zambia; UNC Nicaragua; UNC China; UNC Vietnam (National Hospital for Tropical Diseases and Bach Mai Hospital), UNC South Africa, Child Family Health International, or Himalayan health Exchange . If your host-site is not listed, select NO.
  • make sure to include the full address (including http:)
  • Emergency Contact Information

    Please enter the name of a person (family member, etc.) to contact in case of emergency.
  • Funding Sources

  • not your ONYEN password, not your PID number, just your ONYEN ID, example "seslifko" or "mksmith". Do NOT enter your PID.
  • This must be a med.unc.edu email address.
  • For this field and the following four address fields, enter the address, city, province, zip code equivalent, and country of your DESTINATION. If you don't know the street address of your destination, enter your current home address for this field and the following four fields.
  • City of your current mailing address
  • MM slash DD slash YYYY
  • By checking this box, you affirm that the information above is accurate, and that you are UNC resident or fellow. For the comments field: Please add the names and birth dates of any family members traveling with you (if applicable).

Next Steps

After submitting this form, you will receive an email (within 5-10 days) stating the amount of money you will need to pay for travel insurance.  You will need to pay online.  You are also required to complete the remaining UNC School of Medicine’s Pre-Travel Requirements before your travel is approved. If you are a student, you will also receive an email- within moments of receiving the email from the OIA- granting you access to the Sakai Course Site where you will find the two required travel modules and corresponding quizzes.

Once this form has been processed and you have completed all other requirements, you will be eligible to apply for credit for your overseas course.