Global Health and Humanitarian Medicine Course Application Form 2021/22

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1 Global Health and Humanitarian Medicine Course Application Form 2021/22 Thank you for your interest in applying for the 2021/22 Global Health and Humanitarian Medicine course. The below application is divided into four sections, please ensure you answer every question in each section. Applications will close at 23:59 BST on 26 th April Please be informed that we could ask you to provide a copy of a recommendation letter from your current or previous direct line manager/supervisor after completing the first round of selection. How we will use your information: MSF-UK collects your personal data on this form for the sole purpose of administering the Global Health and Humanitarian Medicine Course. The data is processed under Article 6(1)(b) (performance of a contract) of the General Data Protection Regulation. It is shared only with the academic institutions providing the course. If unsuccessful in your application, we will securely retain your data for one calendar year. If successful in your application we will securely retain your data for 5 years following your completion of the course, and after this will retain only basic contact information in order to maintain records of the course. You have a right to object to the processing of your data, and to complain to the Information Commissioner s Office should you feel our processing of your personal data is not compliant with the law. For full details of MSF-UK s Privacy Policy, and how to contact us, please see our website: Part 1: Personal Details 1. First Name 2. Surname 3. Date of Birth 4. Gender 5. Nationality 6. Current Country of Residence 7. Current Residential Address Address Line 1 Address Line 2 Address Line 3 City/Town State/Province ZIP/Postal Code Country 8. Address

2 9. Phone Number 10. Current Employment (Name/address of your affiliation, organisation, institution) 11. Your position 12. Have you applied for the GHHM course before? 13. If yes, in which year did you submit your application? 14. Are you currently enrolled in a graduate or diploma programme (including an online course)? 15. Have you applied to any other graduate or diploma programme (including online course) and are awaiting results for selection to start the programme while you would be enrolled on the GHHM course? 16. The GHHM course is an English Language course. A good standard of English comprehension is required. Please rate your English Communication skills: Speaking: Native Fluent Intermediate Beginner Listening: Native Fluent Intermediate Beginner You will be required to demonstrate your English Language proficiency in the Personal Statement section. Part 2: Curriculum Vitae 17. Medical Degree Year of Graduation 18. Medical Degree University University Name: City: Country: 19. Current Medical Speciality (e.g. paediatrics, emergency medicine etc.) 20. Years of medical practice since graduating (excluding the mandatory internship) 21. Current country of medical practice (drop down menu) 22. Are you currently working for MSF? (Please note your answer will not impact your application). Yes/No 23. (if no) Have you previously worked for MSF? (if no) continue to question 25) (If yes) Operational Centre:

3 Country: Mission/Project: Dates: 24. (if yes to Q18) Operational Centre: Country: Mission/Project: 25. Is MSF paying for your course fees? Yes No Partial (please provide details) 26. FOR INTERNAL MSF CANDIDATES ONLY: Do you have approval from your line manager to apply for this course? Yes/No (if yes) Name of Line Manager: Address: Part 3: Course Administration 27. Where will you be based for the duration of the course? (Please indicate Country/City e.g. Nigeria/Lagos) 28. Are you able to commit to attend at least 70% of lectures, participate in at least 70% of group activities and commit 4-5 hours per week to self-directed online learning? Failure to meet these criteria will mean that we cannot declare you as eligible to sit the DTM&H exam 29. Are you preparing for other exams in the next 12 months, or do you have other competing commitments? Yes/No If yes please explain your other commitments and how you might be able to manage 70% attendance and 70% group work participation (6-8 hours per week)

4 30. Are you planning to travel or spend time working oversees while completing the GHHM course? Yes/No If yes, please give an indication of your plans. 31. The GHHM course prepares you to sit the DTM&H exam which is run by the Royal College of Physicians. Do you intend to sit the DTM&H exam in 2022? Yes/No 32. How did you hear about the GHHM course? (Drop down menu) - Word of mouth - GHHM webpage - Learning & Development Catalogue - Facebook - Line Manager/Head of Mission - Other Part 4: Personal Statement Your personal statement is the main component of your application. Your answers to the next 8 questions will be used to shortlist your application. Please take time in answering these questions. Write in full sentences and make sure you answer ALL questions. You have 150 words per question. 1. Please state your motivation to apply for this Course. Please tell us your particular interest in the field of both Tropical and Humanitarian Medicine and what you have done to demonstrate this interest through your career to date? (E.g., previous work experience, current employment, conference attendance). If any of the above-mentioned work experiences were based in low and middle-income countries (LMICs), please elaborate? (answer between words)

5 2. Do you have any qualifications in the field of tropical/humanitarian medicine? (For example, any trainings, teaching experience, publications you have been involved in, bursaries, prizes, quality improvement.) 3. Why did you choose the GHHM course? 4. Please describe your expectations from this course. 5. The GHHM course is founded on the principle of Blended learning. What do you understand by it, and how will you strike a balance between the requirement of 6-8 hours of weekly self-directed learning for the course and your professional and personal commitment? (answer between words)

6 6. What do you understand by peer learning and how will you contribute to the course? (answer between words) 7. Have you ever worked/engaged in projects/ programme/activities in the field of Tropical/Humanitarian Medicine? (if yes, please give details of your experiences) 8. Please tell us your future career plans after completing this course - do you have any concrete plans to use your qualification in the field of tropical/humanitarian medicine? I acknowledge that the information provided above is true and correct to the best of my knowledge. I understand and agree that if selected, I will be required to pay the required amount of course fee before the deadline and be required to attend at least 70% of the educational activities to complete the program. Yes, I understand and agree that I will meet all the necessary course requirements. No

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