THE WARREN ALPERT MEDICAL SCHOOL OF BROWN UNIVERSITY Policies and Procedures for Visiting International Exchange Students The following is a checklist of documents and information which we ask you to provide for medical students nominated to come to Brown. Curriculum vitae of student. Letter of support from Dean of Students or other appropriate administrative officer. Current official transcript. Proof of health insurance which must cover dates of stay at Brown and include repatriation of remains). We suggest using HTH Worldwide s Accident and Sickness Plan for International Participants available at http://www.brown.edu/administration/office_of_insurance_and_risk/shared/hthinternation alhealthinsurance.html. BROWN FORMS to be completed or provided by student Clinical elective application. Statement by the Dean of your medical school DS2019 information sheet. Copy of your passport s biographical page and photo. Health insurance memo of understanding (Brown OISSS form) Immunization form (Brown form) Please note: TB SCREENING must provide proof of TWO Tuberculosis Skin tests (PPD) at least 2 weeks apart, done within 6 months of expected arrival at Brown University. List of full-time, hands-on clerkship experience. Bank or sponsor verification of personal funds. Guiding Principles of Professional Behavior. Receipt of these documents in a timely manner is appreciated. Students must plan their travel to arrive in Providence NO LATER THAN THURSDAY of the week prior to beginning their first elective. *Note: Malpractice insurance is provided to exchange students by Alpert Medical School. Dean Julianne Ip Warren Alpert Medical School of Brown University Providence, RI 02912, USA Telephone inquiries: 401-863-9790 Email inquiries: Hilary_Sweigart@Brown.edu (August 2012) 1 10/22/12
Date (month, day, year): ALPERT MEDICAL SCHOOL VISITING EXCHANGE STUDENTS Clinical Elective Application Last Name, First Name, Middle Name: Email Address: Telephone Number: Country of Citizenship: Mailing Address: Home Medical School: Year of Graduation from Medical School: Gender: Date of Birth (month, day, year) NUMBER OF ELECTIVES How many months will you be at Alpert Medical School (AMS)? (This will be governed by the exchange agreement your school has with AMS.) Write the dates for your electives below by using Alpert Medical School s elective calendar http://brown.edu/academics/medical/education/clerkship-calendar. COMMENTS: 2 10/22/12
ELECTIVES DESIRED: Check out the elective catalog at (http://brown.edu/academics/medical/download/clinical elective listingvisiting students ) Please note that due to an increase in the size of classes at Alpert Medical School and the number of visiting medical students, elective choices may be very limited. So provide plenty of choices. I am interested in the following electives: Elective Number Elective Title 3 10/22/12
THIS STATEMENT MUST BE COMPLETED AND SIGNED BY THE DEAN FROM HOME MEDICAL SCHOOL The medical student named above is in good standing at this institution, is in the FINAL year of a year program, and has approval to take the electives. Has the student attended an educational session on the prevention of bloodborne and airborne pathogen infection in compliance with OSHA regulations? YES NO (circle one answer)* Has the student attended an educational training session on HIPAA? YES NO (circle one answer)** Has the student received the mask fit on the Tecnol PFR95 mask? YES NO (circle one answer)*** At the conclusion of the course/clerkship is an evaluation report required? YES NO (circle one answer) Dean of home medical school must submit a letter attesting to the studentʹs use of written and verbal English sufficient to communicate with patients, medical faculty, and others. Printed Name: Title: Signature: Date: 4 10/22/12
* Educational session on the prevention of bloodborne and airborne pathogen infection in compliance with OSHA regulations. Failure to provide this information will delay your application. If you have not attended such a session, you may fulfill the requirement by taking an online course at http://www.probloodborne.com/en-us/ at a current cost of $19.95. The Certificate must be provided to Alpert Medical School as part of your application. ** Educational training session on HIPAA. Failure to provide this information will delay your application. If you have not attended such a session, you may fulfill the requirement by taking an online course through Alpert Medical School. Instructions for the course are attached at the end of the application packet. *** Mask fit on the Tecnol PFR95 mask. If you have not been fitted for a mask prior to coming to Alpert Medical School, you must arrange through Princess_Booker@Brown.edu for a mask fit appointment on the Friday prior to beginning your first elective. 5 10/22/12
The Warren Alpert Medical School Brown University Visiting International Exchange Student DS-2019 Information Sheet Student First Name: Student Last Name: Gender: Date of Birth (month/day/year): City and Country of Birth: Country of Citizenship: Mailing Address (Street, Town, Postal Code): Email Address: Phone Number: Name of Medical School: Country of Medical School: Date Electives Expected to Begin (month/day/year): Date Electives Expected to Be Completed (month/day/year): For Brown s Office of International Student and Scholar Services: Please provide a copy of your passport s biographical page and a photograph so that Brown s Office of International Student and Scholar Services can complete the issuance of your J-1 DS- 2019 certificate for visa eligibility for your stay at Brown University 6 10/22/12
PROOF OF IMMUNIZATION FORM VISITING INTERNATIONAL MEDICAL STUDENTS Please use this form and do not send separate proof of immunizations Name of Student: Visiting from (name of medical school): INFLUENZA: I will provide proof that I have been vaccinated against influenza within 12 months of arrival at Brown. Tdap: I will provide proof (month/day/year) that I have been vaccinated with Tdap (Tetanus, Diphtheria, Pertussis) within the last 10 years. (Td is no longer acceptable.) HEPATITIS B: I will provide proof of THREE doses of Hepatitis B vaccine (month/day/year) or serologic evidence of Hepatitis B immunity. MEASLES: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of live virus measles (rubeola) vaccine administered at least 28 days apart after my first birthday or positive immunity titers. MUMPS: I will provide proof (month/day/year) that I have been vaccinated with live virus mumps vaccine administered on or after my first birthday, or positive immunity titers. RUBELLA: I will provide proof (month/day/year) that I have been vaccinated with rubella vaccine administered on or after my first birthday or positive immunity titers. VARICELLA: I will provide proof (month/day/year) that I have been vaccinated with TWO doses of varicella vaccine administered 4 8 weeks apart or serologic evidence of varicella immunity. TB SCREENING: I will provide proof of TWO Tuberculosis Skin tests (PPD) at least 2 weeks apart, done within 6 months of arrival at Brown. If I have a non negative result to the test, I will provide documentation of a chest x ray and if indicated, prophylaxis therapy. Immunization Documentation Influenza (shot) within 12 months of arrival at Brown Tdap Booster (within last 10 years) Hepatitis B three doses Measles/Mumps/Rubella Measles (single dose) Mumps (single dose) Rubella (single dose) PPD (*two skins tests at least 2 weeks apart, within 6 months of arrival at Brown) To be completed by student health service representative Month/Day/Year Month/Day/Year Month/Day/Year Placement date 1: Read date 1: Results (in mm) Placement date 2: Read date 2: Results (in mm) Varicella (shots or titer) or send serologic evidence of immunity Student Health Service Representative s Signature, type name and title. Date: 7 10/22/12
Detailed list of all full-time hands-on clerkship experiences you will have completed before participating in clerkships at Brown. Title of Clerkship Specialty (Medicine, Pediatrics, etc.) Duration (in weeks) Was this a handson, full-time experience? If not, explain. Student Name: Date: 8 10/22/12
Brown University Office of International Student & Scholar Services 68 Brown Street, Box 1906 Phone 401-863-2427 Providence, RI 02912 Fax 401-863-7543 Email: oisss@brown.edu www.brown.edu/oisss Health Insurance Information for J-1 Visa Holders U.S. Department of State regulations require all J-1 Exchange Visitors and their accompanying J-2 dependents to have health insurance throughout the period of participation in the Exchange Visitor Program. Minimum acceptable coverage would provide: -medical benefits of at least $50,000 per accident or illness -repatriation of remains in the amount of $7,500 -expenses associated with medical evacuation in the amount of $10,000 -deductible not to exceed $500 per accident or illness Insurance coverage backed by the full faith and credit of the exchange visitor's home government also meets this requirement. If you choose to buy your own health insurance coverage from another source, the insurance corporation underwriting the policy must have one of the following ratings: -an A.M Best rating of "A-" or above -an Insurance Solvency International, Ltd. (ISI) rating of "A-i" or above -a Standard & Poor's Claimspaying Ability rating of "A-" or above -a Weiss Research, Inc. rating of "B+" or above HEALTH INSURANCE MEMO OF UNDERSTANDING For J-1 Exchange Visitors Please sign and date below and bring this completed document with you as you check in with the Office of International Student and Scholar Services, upon your arrival at Brown University. I understand that the U.S. Department of State requires all participants in Exchange Visitor Programs and their accompanying dependents to have health and accident insurance at the required minimum level of coverage. I understand that I am responsible for the purchase of such health insurance. I understand the cost of this insurance. I understand that U.S. government regulations require the University to notify the U.S. Department of State and to terminate my J-1 status if they determine that my family members or I willfully fail to comply with the insurance requirements. I understand the health insurance requirements, the costs involved, and the need to maintain the insurance throughout my stay at Brown University. Name: Signature: Date: OISSS 11/27/06 9 10/22/12
New international health insurance programs available through HTH Worldwide. HTH Worldwide is a leader in helping world travelers gain access to quality healthcare services all around the globe. HTH combines ongoing research, a contracted global community of physicians and hospitals, advanced Internet applications, and wide experience in international health insurance to ensure customers' health, safety and peace of mind. Founded in 1997, HTH Worldwide has grown to become a leading provider of international health insurance programs and services. HTH offers a full range of individual and group specialty health insurance programs, all of which include HTH's Global Health and Safety Services available online, through their 24/7 medical assistance call center and via mobile device. Presently, HTH annually provides health insurance products to over 500,000 individuals who travel, study or live outside of their home country. Accident and Sickness plan for International Participants - Available as of June 1, 2011 This plan is available to international visiting scholars and researchers who come to Brown but who are not enrolled as students and who are not employees of the University. This plan exceeds the US Department of State J-1 Status Visa requirements Learn more or enroll online by using a credit card at www.hthstudents.com. Enter Group Access Code GQE-17728 on the right side of the page. Office of Insurance and Risk 164 Angell Street Box 1848 Brown University Providence RI 02912 10 10/22/12
BANK OR SPONSOR VERIFICATION For presentation at BROWN UNIVERSITY (host university): Visiting students must provide personal funds of a minimum of $2,225 per month for their stay. I. Concerning the applicant himself/herself This is to certify that Mr./Ms.. will have a total of $... available for the purpose of studying in the U.S.A. for an academic semester/year. II. Concerning parents or sponsor of the applicant This is to certify that Mr./Ms.. will have a total of $... available for the purpose of supporting Mr./Ms... During his/her academic year in the U.S.A.. Place/Date. Name of Bank. Signature/Stamp (April 2011) 11 10/22/12
PRINCIPLES OF THE BROWN UNIVERSITY COMMUNITY We, as members of the Brown University community faculty, undergraduates, graduate and medical students, and staff are dedicated to supporting and maintaining a scholarly community in which all share together in the common enterprise of learning. As a central aim, Brown University promotes intellectual inquiry through vigorous discourse, both oral and written. The fundamental principles that must necessarily undergird this aim include respect for the integrity of the academic process; individual integrity and selfrespect; respect for the freedoms and privileges of others; and respect for University resources. In becoming a part of Brown University, we accept the rights and responsibilities of membership in the Universityʹs academic and social community, and assume the responsibility to uphold the Universityʹs principles. RESPECT FOR THE INTEGRITY OF THE ACADEMIC PROCESS The rights and responsibilities that accompany academic freedom are at the heart of the intellectual purposes of the University. Our conduct as community members should protect and promote the Universityʹs pursuit of its academic mission. We are all, therefore, expected to conduct ourselves with integrity in our learning, teaching and research, and in the ways in which we support those endeavors. INDIVIDUAL INTEGRITY In order to ensure that the University can dedicate itself fully to its academic and educational vision, it is expected that an individualʹs personal integrity will be reflected not only in honest and responsible actions but also in a willingness to offer direction to others whose actions may be harmful to themselves or the community. The University expects that members of the Brown community will be truthful and forthright. The University expects that community members will not engage in behavior that endangers their own sustained effectiveness or that has serious ramifications for their own safety, welfare, academic well being or professional obligations, or for that of others. RESPECT FOR THE FREEDOMS AND PRIVILEGES OF OTHERS We strive for a sense of community in which the individual growth of all members is advanced through the cultivation of mutual respect, tolerance, and understanding. Brown University values and encourages individuality while also affirming the community dimensions of academic life. A socially responsible community provides a structure within which individual freedoms may flourish without threatening the privileges or freedoms of other individuals or groups. The University is committed to honest, open, and equitable engagement with racial, religious, gender, ethnic, sexual orientation and other differences. The University seeks to promote an environment that in its diversity is integral to the academic, educational and community purposes of the institution. RESPECT FOR UNIVERSITY RESOURCES All community members must respect the general resources and physical property of the University. Such resources are assets in which community members have a vested interest, as these resources specifically support the institutional mission. 12 10/22/12
STANDARDS OF CONDUCT The principles stated above are values that hold for the entire University community. Specific standards of conduct and procedures for redress of violation of those standards for each segment of the community can be found in the following University documents: The University subscribes to an academic code. All students are expected to have read the academic code booklet, to be familiar with its principles, and to sign a statement acknowledging their responsibility for the code The standards and procedures for all students may be found in Brown University Student Rights and Responsibilities, published by the Office of Student Life. Medical students should look also to the Guiding Principles of Professional Behavior, set forth by the Brown Medical School, for additional information For specific information on rights and responsibilities, faculty should consult the Handbook of Academic Administration, which puts into practice the principles outlined in the document Faculty Rules and Regulations. Policies and procedures guiding staff conduct may be found in the Brown University Human Resources Policy & Procedure Manual, provided by the Human Resources department. GUIDING PRINCIPLES OF PROFESSIONAL BEHAVIOR THE WARREN ALPERT MEDICAL SCHOOL ʹIʹhe mission statement of The Warren Alpert Medical School exhorts the members of the medical school community to view medicine ʺas a noble profession rather than a trade to be learned.ʺ We seek to graduate physicians who are socially responsible and committed to improving health care in their community, the nation and the world. To these ends, we strive to create and sustain a learning environment that nurtures the full development of our professional values. The Guiding Principles of Professional Behavior is informed by the altruistic tradition of medicine and proclaims our aspirations regarding what it means to be a professional in the context of our academic and clinical environments. Patient Advocacy. Patient care comes first. Socially responsible physicians undertake to improve the health of their patients, families and communities through their devotion to medicine and their advocacy for better health for all. Students and faculty participate in community outreach and advocacy and cultivate respect for cultural diversity. Faculty serves as role models and mentors for students, residents and fellows in striving to improve health care in the community, and to ensure. that all patients regardless of their socioeconomic position receive quality health care. Respect for Others. Professionalism requires recognition of and respect for other persons. In the clinical setting, we are respectful and responsive to patients, their families, peers and the health care staff. In the academic context, faculty and administrators demonstrate respect by teaching or communicating in a thoughtful and sensitive manner. Students, residents and fellows reciprocate by participating constructively in teaching sessions and by providing and responding to appropriate feedback to and from faculty and administrators. Ethical Practice. In maintaining the public trust, all members of the medical school community strive to sustain the highest standards of academic and personal honesty, compassion, integrity, altruism, and dependability. The medical school promotes moral development by acting ethically and by setting and maintaining the highest ethical standards for faculty, staff and students. We take responsibility not only for our own behavior but that of our professional colleagues. In daily conduct with patients and with each other, 13 10/22/12
we are fair and truthful. We act in a compassionate manner. In our professional communications, we report accurately and objectively, particularly when documenting patient care and in conducting research. When appropriate, we provide complete disclosure of self interest and avoid and appropriately manage conflicts of interest. Self Care and Self Awareness. Recognizing that devotion to the profession can only be sustained in a life that is meaningful and balanced, the medical school expects its members to attend to their own health, emotional and social needs and well being. Reflective professionals are aware of their obligation to themselves, their family, their community and patients to maintain good health. They are thoughtful about what in their lives has personal meaning including their professional and personal values, priorities and commitments. Autonomy and Academic Freedom. The medical school respects the autonomy of patients, students, residents and fellows. In caring for patients, we honor and uphold the principles of informed consent and shared decision making. We understand and respect the professional boundaries of the physician/patient and the teacher/student relationships. Our trainees are encouraged to shape their own learning to develop leadership skills and to pursue career and outside interests. As a community, we support the responsible exercise of freedom of speech and academic freedom. Such free and open communication may be required to advocate effectively for patient care. Lifelong Learning. As members of the The Warren Alpert Medical School community we have a continuing commitment to excellence in clinical practice and in scholarship. We are committed to lifelong learning through participation in continuing education, and to facilitating ongoing opportunities for students, residents, fellows and faculty to participate in professional development that enhances innovation and creativity in their teaching and scholarship. I have read the Principles of the Brown University Community and the Guiding Principles of Professional Behavior of The Warren Alpert Medical School and pledge to adhere to them. Signature Date Printed Name 14 10/22/12
Online HIPAA Training Instructions Brown University is a member of the Collaborative Institutional Training Initiative (CITI), which is hosted by the University of Miami. To complete your HIPAA training, you will complete two brief online training modules, as well as the quiz at the end of each module. The entire process can be completed in less than one hour. Important note: when you have completed the modules and quizzes, be sure to convert your Completion Report to a.pdf and email it to Princess Booker (Princess_Booker@brown.edu) Instructions on how to do this are at the end of this document. To Access the Online HIPAA Training modules Step 1: Go to http://www.citiprogram.org Click on the New Users Register Here link in the middle of the page (see below) Step 2: Register to use the site: A. Under Select your institution, click the pulldown menu to the right of the box under Participating Institutions and choose Brown University B. Follow the instructions to create a Username and Password Username must be between 4 and 50 characters and is not case sensitive. Your username can include letters, numbers, a period, an underline or the @ symbol. 4/28/09
Password must be between 8 12 characters, also not case sensitive, and can only include letters and numbers C. Enter your first and last name D. Enter your email address. You are given the option of entering 2 email addresses. E. Click Submit at bottom of page Step 3: Answer Required Questions On the next page, answer the questions marked with an asterisk: Language Preference Institutional email address (use Princess_Booker@brown.edu) Gender Highest Degree Department (use Alpert Medical School Exchange Student) Role in Research (use Student Researcher Graduate Level) Office Phone: (use 401 863-2293) May we contact you to complete a course survey (yes or no) Click Submit at bottom of page Step 4: CITI Course Enrollment Procedure A. Scroll to the bottom and click the link Continue to Question 1 at this time B. The next page is titled CITI Course Enrollment Questions Under #1 Human Subjects Research, click in the box next to the words Group 4: HIPAA training for Alpert Medical Students C. Click Submit at bottom of page D. The next page says Select Your Institution or Organization. Since you already selected Brown University at the beginning of the registration process, click NO at the bottom of the page Step 5: Taking the Training Modules A. From the Main Menu page, click the word Enter in the middle of the page, as shown below: - 2 -
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B. On the next page, click The Integrity Assurance Statement link, as shown below: C. Read the text on that page and select the appropriate statement at the bottom of the page and click the Submit button D. Click the link under Required Modules that is labeled HIPAA and Human Subjects Research. This brings you to the first training module, which takes 10 15 minutes to complete. Step 6: Taking the Quiz A. Once you ve read the text, take the quiz, which consists of 2 questions, by clicking the link at the bottom of the page (see below) B. Generate the quiz by clicking the appropriate link (see below) C. Once you have answered the two questions for this module, click the Submit button and you will see your results. D. At this point, you can: Go to the next training module, Privacy Rules: Students and Instructors Go to gradebook Go to the Main Menu and log out View the HIPAA training module again - 4 -
Submit a comment about the module Step7: After Completing both Training Modules and Quizzes A. Go to the Main Menu B. Print your Completion Report and save for your records (sample below). C. Save the Completion Report as one of the following formats: 1. PDF: right-click while the completion report is open and choose Convert to PDF 2. Word doc: copy the document and paste it into Word 3. Go to the File menu and choose Save As and select Text File (.txt) as the type. D. Name the saved file HIPAA training, followed by your last name. Example: HIPAA training. YOURLASTNAME E. Email the.pdf to Princess_Booker@brown.edu so the date that you completed the modules will be entered into our database. That s it you re done! Thanks for completing your HIPAA training course! - 5 -