Please answer all questions to the best of your ability
not all questions may apply.

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1. Institution:

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2. Address:

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3. Applicant Name:

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4. Applicant Email:

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5. Applicant PGY year:

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6. Any subspecialty interest:

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7. Applicants previous global health experience:

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8. Supervising ACEPS Faculty Name:

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9. ACEPS Faculty Email:

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10. Supervising ACEPS Faculty international experience:

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11. Supplemental funding sources – please describe:

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12. Name of participating Global Health Organization (if any):

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13. Name(s) of In-Country Supervising Faculty (if any):

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14. Upload Applicant CV

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Choose File

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15. Please describe the exact nature of the proposed experience (please comment on duration, location, goals/objectives, and planned education/training initiatives of in-country providers vs. clinical care provision)

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16. What do you hope to learn from this experience?

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17. Please outline if, and in what form, the collaboration with the host institution will continue beyond the award period.

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18. If awarded this opportunity, are you willing to report your experience at the ACEPS Winter Meeting? This would be at the 2027 Annual Meeting slated for February 5-7, 2027, in Salt Lake City, Utah.

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