Elective Eval Form-Global Medical Education

Name

Degree Program

Year of Graduation

Preferred Email:

Cell

Are you an International Research Award recipient?:

Yes

No

Are you in the Global Health track (SCGH)?:

Yes

No

International Elective Travel Site(be specific):

Dates of Travel:

Stony Brook Elective Supervisor/Mentor:

International Site Supervisor/Mentor:

Site Supervisor email/contact information:

NGO Website (if applicable):

Project description:

For elective credit list 4 goals and objectives:

Did the elective enable you to meet these goals and objectives?

Yes

No

What were your roles and responsibilities on the project/elective?

Describe your living quarters:

Dorm

Apartment

Host Family

Other (specify

Housing Recommendation (if any):

Please Comment on the Safety and Security of your travel and setting:

List any Sponsors, e.g. International Fellowship, Alumni Association Fund, other funding:

Total Cost of Trip: $

Rate Overall Experience:

Poor

Fair

Good

Outstanding

Rate your mentors/supervisors

Poor

Fair

Good

Outstanding

Would you recommend this site to another student

Yes

No

Describe in your own words the strengths, weaknesses, caveats, etc. of this experience:

Additional Suggestions for future students at this site:

How would you rate the Office of Global Medical Education?

Are there ways in which the Office of Global Medical Education can be improved? Please comment

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