General Information

Name:

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* 1. Name:

Which level student are you?

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* 2. Which level student are you?

During which academic year did you complete this international elective?

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* 3. During which academic year did you complete this international elective?

Which student group were you a member of for this international elective?

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* 4. Which student group were you a member of for this international elective?

Dates of Rotation/Elective (DD/MM/YY - DD/MM/YY):

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* 5. Dates of Rotation/Elective (DD/MM/YY - DD/MM/YY):

In what country was your international elective site located?

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* 6. In what country was your international elective site located?

In what city/town was your international elective site located?

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* 7. In what city/town was your international elective site located?

Name of Host Organization/Institution:

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* 8. Name of Host Organization/Institution:

Name of Preceptor/Mentor:

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* 9. Name of Preceptor/Mentor:

Total cost of elective:

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* 10. Total cost of elective:

Did you receive a scholarship for this elective (check all that apply)?

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* 11. Did you receive a scholarship for this elective (check all that apply)?

Before leaving the United States, approximately how many hours did you spend planning this elective? Please provide your best estimate.

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* 12. Before leaving the United States, approximately how many hours did you spend planning this elective? Please provide your best estimate.

Approximately how many hours did you spend working/engaged in work at your elective site? Please provide your best estimate.

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* 13. Approximately how many hours did you spend working/engaged in work at your elective site? Please provide your best estimate.

How many people/patients benefited from your work at this elective site? [Approximately how many people did you interact with while on this rotation? Please provide your best estimate considering all of the patients you saw, the number of people who participated in a survey, the number of people reached through health education, etc.]

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* 14. How many people/patients benefited from your work at this elective site? [Approximately how many people did you interact with while on this rotation? Please provide your best estimate considering all of the patients you saw, the number of people who participated in a survey, the number of people reached through health education, etc.]

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