Information Form to be completed by students and residents who have already been accepted to the International Family AIDS Program and will be traveling to stay in La Romana for a period of weeks or months. Please send the completed form or equivalent information to both Andy Dean and Consuelo Beck-Sagué at the email addresses under Contacts on the www.familyaids.org website.
Name _________________________________ Home telephone ___________
Cell phone _____________________________ Email address ________________
Anticipated rotation dates (please email us your travel itinerary when available):
I. Work Experience, Education and Research
a. Current employment (if medical resident please state which year and which field of medicine):
b. Education (please list past degrees and state current school year if you are in medical or public health school now):
c. Describe any previous international work experience (please include which country, when you were there and what you did – both medical and non-medical work):
d. Have you done any HIV related work in the past? Please describe.
e. Research (describe any basic science, clinical, epidemiology experience):
f. Please describe specific areas of interest (take a look at the www.familyaids.org website under “Students and Residents” – slides 30-31 for some ongoing clinical projects for HIV/AIDS care and prevention in La Romana):
II. Goals
a. What are your professional and personal goals for this rotation?
b. What are your general career goals?
III. Medical Background and Emergency Contacts
a. Do you have any physical or medical conditions that might require access to medication, special consideration in case of accident? (diabetes, epilepsy, current medication, allergies, etc.):
b. Any special physical requirements (stair problems, heat problems, hearing, vision, etc.):
c. Special dietary considerations (vegetarian, kosher, food allergies, etc.):
d. Who we should contact if an injury or need for communication occurs (2 Contacts)
|
Emergency Contact Name |
Relationship |
Phone (Home) |
Phone (Cell) |
|
|
|
|
|
|
|
|
|
|
|
|
|
IV. Travel Requirements
Are you a US citizen? Yes No
If not, are you a permanent resident? Yes No
If you are a US Citizen then all you need is a valid US passport to enter the DR. If you are not a US citizen, there may be visa requirements that you may need to investigate well ahead of time. Check the New York DR consulate website
http://www.consuladord-ny.org/Servicios/servicios-Ingles.htm (Phone # 212 768-2480)
for visa requirements. If you are not a New York resident then contact your nearest local Dominican Repbulic consulate V. Language Skills - Spanish experience:
If you have studied Spanish please let us know what stage of schooling and how many years total: Please check the level of Spanish best describes you (See Below for descriptions): Totally Fluent Conversant Intermediate Beginner
I Totally fluent in Spanish--native speaker or very advanced
Can take a medical history and understand everything the patient and relatives say
Can give a lecture on a familiar subject in Spanish, as easily as in English
Can write a report in Spanish with correct grammar
II. Conversant
Can understand a lot of what's going on, but would not be able to give a lecture without practice
Can communicate, administer questionnaires, and instruct patients on taking medicines Can write notes in Spanish, fill out forms
III. Intermediate
Can order food and get around, but need help in detailed communication such as comforting a family member, following guidelines in Spanish, or participating in a meeting
Can follow an adult conversation
IV. Beginner
Can form some sentences, understand some or most simple comments or commands
Need an interpreter for most interactions
VI. Other Skills that might be useful for this Rotation
Describe computer skills/interests:
Tell us about other skills/interests (computers, auto mechanics, painting, administration, art, etc.):
***Please feel free to attach resume or personal statement if you would like purely for informational purposes!