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UCSD School of Medicine
Study Abroad Check List 

Medical students studying abroad must complete this form and submit to Adrianne Edwards in the UGME office before departure. 

Initial When Completed: 

_____	I have consulted the UCSD Student Health Service Travel Clinic ((858) 534-2918 or (858) 534-3300 or http://studenthealth.ucsd.edu/travelclinic.shtml) or another appropriate resource such as the County Health Department http://www.immunization-sd.org/parents/eng/travel.html for advice and recommendations.
_____	I have accessed the Center for Disease Control net site (http://www.cdc.gov) for information about travel recommendations and immunizations.
_____	I have received the appropriate immunization for the travel I have planned.
_____	I am aware that many developing countries have a high prevalence of HIV infection and that appropriate infection control practices may not be practiced in some areas. I am prepared to practice universal precautions and I take responsibility for ensuring my access to appropriate antiretroveral medications should a high risk exposure to blood or other body fluids occur.
_____	I have accessed the State Department through their web site (http://travel.state.gov/).

SIGNATURE: _____________________ 

DATE: ___________________________ 

Name and address of a contact person in the USA who may be reached at any time by the UCSD School of Medicine and through whom messages can be relayed to the student: 

Name: _____________________________________________________________________ 

Relationship to student: __________________________________________________ 

Address: ___________________________________________________________________ 

Work number: (    )____________________ 

Home number: (    )_____________________ 

Email address: _________________________