Visit Pre-Approval Status: Trainee Reviewers (if applicable): ______ Visit Status:
Last Name:
* must provide value
First Name:* Last Name:* Email Address:* Alternate Email Address (optional):
First Name
* must provide value
Last Name
* must provide value
E-mail Address
* must provide value
Please provide a telephone number where you can be reached before your visit to Kenya.
Are you completing this form on behalf of someone else? Or, if completing the form yourself, is there someone else you would like to have copied on emails related to your visit?
Yes
No
Please provide this person's contact information so that they may be copied on any emails sent:
First Name: Last Name: Email Address:
What is your primary institutional affiliation?*
* must provide value
Benemérita Universidad Autónoma de Puebla Brown University Dhulikhel Hospital Duke University Indiana University Kaiser Permanente Kathmandu University Linköping University Mount Sinai School of Medicine New York University Purdue University Stanford University Tamale Teaching Hospital University for Development Studies School of Medicine University of Alberta University of California San Francisco University of Louisville University of Texas at Austin University of Toronto University of Virginia Other
Other Institutional Affiliation:*
What is your primary role?*
* must provide value
Faculty Resident Fellow Staff Trainee/Student Volunteer Other
What is your primary academic/clinical discipline?*
* must provide value
Adolescent Health Agriculture Anesthesia Basic Sciences Biostatistics Business Cardiology Cardiothoracic Surgery Dentistry Dermatology Emergency Medicine Engineering Family Medicine Gastroenterology General Internal Medicine General Pediatrics General Surgery Geography Gyn Onc Hematology-Oncology Infectious Diseases Journalism Law Medicine (Students) Neonatology Nephrology Neurology Nursing Ob/Gyn Occupational Therapy Opthalmology Orthopedics Otolaryngology Palliative Care Pathology/Lab Med Peds Oncology Pharmacy Physical Therapy Plastic Surgery Psychiatry Public Health Pulmonary Radiology Sociology Thoracic Surgery Toxicology Urology Other Test Discipline
Medical Students: please select "Medicine (Students)."
Please upload a copy of your CV in PDF format.
Moi Teaching and Referral Hospital currently requires that all non-trainee visitors provide a copy of their CV.
Is this your first visit to AMPATH Kenya?*
* must provide value
Yes
No
M-D-Y
Eldoret Departure Date
* must provide value
M-D-Y
Total Number of Days in Eldoret
* must provide value
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Please note that due to common flight arrival times, you may arrive in Eldoret one day after your expected arrival in Nairobi.
Eldoret Arrival Date* Eldoret Departure Date*
Why are you visiting AMPATH?*
* must provide value
Please select all that apply.
PLEASE NOTE: if you are not participating in a clinical rotation but would like to shadow or visit the MTRH wards or any other clinical spaces of the MTRH campus for any period of time during your visit, please still select " Clinical care program" above.
Other Purpose:
* must provide value
Please provide the name and email address of your primary home institution contact for this experience.
First Name:* Last Name:* Email Address:*
Please provide the name and email address of the person who will serve as your on-site supervisor for this experience.
First Name:* Last Name:* Email Address:*
On-Site Supervisor First Name
* must provide value
On-Site Supervisor Last Name
* must provide value
On-Site Supervisor Email
* must provide value
Home Contact First Name
* must provide value
Home Contact Last Name
* must provide value
Home Contact Email
* must provide value
Visit Description*
Please provide a brief description of the work you plan to do while there, including meetings, work-related activities, work locations and project(s) on which you are working. If you selected research as one of the purposes for your visit, please provide a brief description of your research.
* must provide value
Contacts Please list the names and email addresses of the primary Kenyan and North American/European contacts with whom you have been working to plan this visit (leave blank if not applicable) .
Kenyan Contact First Name Last Name Email
North American / European Contact
First Name Last Name Email
Please list the name of any Kenya-based faculty or staff members with whom you plan to meet, if known at this time.
This information allows our team to coordinate visits to avoid overscheduling Kenya-based faculty and staff.
Kenyan Contact First Name
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NA/European Contact First Name
NA/European Contact Last Name
NA/European Contact Email
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Are you visiting primarily to serve as the supervisor for a clinical trainee rotation?*
* must provide value
Yes
No
Do you plan to participate in any direct patient care during your visit?*
* must provide value
Yes
No
Do you plan to initiate any new research during your time in Kenya?*
* must provide value
Yes
No
Clinical rotation opportunities may exist, space permitting, for trainees currently affiliated with a non-AMPATH member institution. Preferences will be given to trainees who have previously completed a rotation with AMPATH Kenya. Please complete the section below to provide additional information on your background and interest in the rotation.
Please share any alternate availability you have for this rotation outside of the dates entered above, if applicable.
Please upload a copy of your CV in PDF format.*
* must provide value
Have you previously completed a rotation with AMPATH Kenya?*
* must provide value
Yes
No
In what capacity did you previously rotate in Kenya?*
* must provide value
Student Resident Faculty Fellow Other
With which institution were you affiliated?*
* must provide value
American Medical Informatics Association (AMIA) Brown University Columbia University Duke University George Washington University Indiana University Indiana University - Purdue University in Indianapolis (IUPUI) Johns Hopkins University Kaiser Permanente Linköping University Moi Teaching and Referral Hospital Moi University Mount Sinai School of Medicine New York University Purdue University Stanford University Syracuse University University of Alberta University of California San Francisco University of Massachusetts University of Missouri University of North Carolina University of Notre Dame University of Texas at Austin University of Toronto University of Washington University of Virginia Vanderbilt University World Bank Yale University Other
Prior Rotation Start Date*
* must provide value
M-D-Y An estimated date will be accepted.
M-D-Y An estimated date will be accepted.
Agriculture Anesthesia Basic Sciences Biostatistics Business Cardiology Dentistry Dermatology Emergency Medicine Engineering Family Medicine Gastroenterology General Internal Medicine General Pediatrics General Surgery Geography Gyn Onc Hematology-Oncology Infectious Diseases Journalism Law Neonatology Nephrology Neurology Nursing Ob/Gyn Opthalmology Orthopedics Otolaryngology Pathology/Lab Med Peds Oncology Pharmacy Plastic Surgery Psychiatry Public Health Pulmonary Radiology Sociology Urology Other
If multiple, please select 'Other' and list all specialties below.
Please provide a brief statement explaining your career goals and interest in/commitment to global health.*
* must provide value
Why do you want to complete a rotation with AMPATH Kenya? How will this rotation fit with the career goals you listed above?*
* must provide value
Please explain how AMPATH Kenya provides unique learning opportunities for you not offered by your home institution.*
* must provide value
Why am I required to provide this information? You indicated above that you are a ______ research project . All ______ s are required to provide additional information about their planned activities and faculty supervision for their visit.
What you'll need . . . On this form, you will be asked to provide the following information prior to your arrival in Kenya:
Activity Description - a short 1-2 paragraph description of the service, education, or research activities the trainee will engage in while in Kenya including the title(s) of the projec(s) the trainee will work on during their stay; Work Location(s) - Location(s) where the trainee will engage in their planned activities; Local Transportation Plan - a description of how the trainee will travel to and from primary work location(s); Mentors & Onsite Administrative Coordinator - Names and contact information of Kenyan and Non-Kenyan mentors and onsite administrative coordinator. If you are planning to initiate a new research activity during your time in Kenya you must also complete the following:
New Study Review & Approval - Trainees proposing new research projects must complete the AMPATH review process for new research as described in AMPATH's Research Project and Grant Development SOP . Confirmation of this approval must be provided. IRB & IREC Approval - After completing the AMPATH Review, all new research projects are required to obtain approval by Moi's Institutional Research Ethics Committee (IREC) and the mentor's IRB. Instructions for IREC approval are online, www.irec.or.ke, and approvals should be uploaded to this form prior to the initiation of any research project. Don't have everything you need now? Don't worry! You can save and return to this form at any time by selecting the "Save & Return Later" button at the bottom of this page. Be sure to write down the return code so you can easily access your record when you return
Questions? If you have any questions as you complete this form, please contact the AMPATH Research Program Office, research.manager@iukenya.org , for assistance.
Before traveling to Kenya, all trainees must identify a faculty mentor/supervisor who will be responsible for overseeing their work in Kenya. The international research mentor must hold a full time appointment at an AMPATH consortium member institution . The international mentor is responsible for:Guiding trainees in the development and execution of appropriate service, training, or research activities in Kenya; Serving as a co-investigator and/or co-author as needed; Assisting trainees in identifying Kenyan co-mentor(s)/supervisor(s); Coordinating with Kenyan co-mentor(s)/supervisor(s) to oversee trainee activities in Kenya; Communicating regularly with the Kenyan co-mentor/supervisor and trainee to coordinate trainee activities in Kenya; Identifying an onsite administrative coordinator to oversee trainees when the international research mentor is not onsite in Kenya; Checking in with trainees on a regular schedule (best practice recommendation is every two weeks for most trainees), either in person when in country, or via phone and/or video conference when not in Kenya; Notifying the AMPATH Research Program Office of any changes in trainee research activities; and Ensuring trainees comply with all applicable AMPATH policies and procedures for research and trainee engagement in Kenya.
American Medical Informatics Association (AMIA) Brown University Columbia University Duke University George Washington University Indiana University Indiana University - Purdue University in Indianapolis (IUPUI) Lehigh Valley Hospital Moi Teaching and Referral Hospital Moi University Mount Sinai School of Medicine New York University Providence Portland Medical Center Purdue University Syracuse University University of California San Francisco University of Massachusetts University of Missouri University of North Carolina University of Notre Dame University of Toronto University of Utah University of Washington World Bank Yale University Linköping University University of Virginia Other
Kenyan Phone Number (if available)
eg. 011-254-53-203-2857
All trainees must also identify a mentor from the Moi University and/or MTRH faculty, staff, or a qualified AMPATH community partner . The Kenyan mentor is responsible for:Serving as a co-investigator and/or co-author on the trainee's project(s) and a co-author on all papers emanating from research conducted by the trainee, unless the mentor declines authorship. Coordinating with international co-mentor(s) to oversee and guide the development and implementation of trainee research activities; Meeting with mentored trainee(s) on a regular basis to obtain updates on their activities and discuss any issues arising; Communicating regularly with the international mentor about trainee activities; and Ensuring trainees comply with all applicable AMPATH policies and procedures for trainee engagement in Kenya.
Moi Teaching and Referral Hospital Moi University Other
eg. 011-254-53-203-2857
All trainees must have an onsite administrative coordinator while on-the-ground in Kenya. The onsite administrative coordinator is responsible for responding to trainee safety, security, and personal conduct concerns while a trainee is on-the-ground in Kenya. The international research mentor may serve as the trainee's onsite Administrative Coordinator as long as the international research mentor will be present in Kenya for the duration of the trainee's stay. If the international research mentor is not able to be onsite in Kenya for any portion of the trainee's stay, the mentor must identify a qualified onsite faculty or staff member from an AMPATH consortium member institution to serve as the trainee's onsite administrative coordinator. The onsite administrative coordinator is responsible for:Responding to safety and security concerns raised by or pertaining to the research trainee(s); Serving as an emergency contact for research trainees while in Kenya; Ensuring research trainee(s) comply with all AMPATH policies and procedures and safety, security, and personal conduct guidelines; and Checking in with trainee(s) on a regular basis to address any issues of concern in order to elevate serious issues to home institution leadership. Will your international mentor, ______ ______ Onsite Administrative Coordinator ?*
* must provide value
Yes No
Please provide the name and contact information of the qualified faculty/staff member from an AMPATH consortium member institution who will serve as your onsite administrative coordinator during your visit.
American Medical Informatics Association (AMIA) Brown University Columbia University Duke University George Washington University Indiana University Indiana University - Purdue University in Indianapolis (IUPUI) Lehigh Valley Hospital Moi Teaching and Referral Hospital Moi University Mount Sinai School of Medicine New York University Providence Portland Medical Center Purdue University Syracuse University University of California San Francisco University of Massachusetts University of Missouri University of North Carolina University of Notre Dame University of Toronto University of Utah University of Washington World Bank Yale University Linköping University University of Virginia Other
eg. 011-254-53-203-2857
All proposed trainee activities are reviewed to confirm proposed activities are aligned with AMPATH mission, values, and strategic priorities and ensure compliance with all applicable AMPATH policies and procedures.
When will you start work in Kenya?*
* must provide value
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When will you finish work in Kenya?*
* must provide value
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What is the primary site for your activities while in Kenya?*
* must provide value
AMPATH Centre Angurai Health Centre Bokoli Health Centre Bumala A Health Centre Bumala B Health Centre Burnt Forest Sub-District Hospital Busia District Hospital Chandaria Centre Chebiemit District Hospital Chepkorio Health Centre Cherangany Health Centre Chulaimbo Sub-District Hospital Huruma Sub-District Hospital Iten District Hospital Endebess Sub-District Hospital Kacheliba District Hospital Kapenguria District Hospital Kapsara District Hospital Khunyangu Sub-District Hospital Kitale District Hospital Matayos Health Centre Moi Teaching and Referral Hospital (MTRH) Moi's Bridge Health Centre Mosoriot Rural Health Training Centre Mt. Elgon District Hospital Mukhobola Health Centre Osieko Dispensary Port Victoria Sub-District Hospital Saboti Sub-District Hospital Sigor Sub-District Hospital Soy Health Centre Teso District Hospital Tot District Hospital Turbo Health Centre Uasin Gishu District Hospital Webuye District Hospital Ziwa Sub-District Hospital Other (Not Listed)
Other Works Site Location
Will you engage in work activities at any other location(s)?*
* must provide value
Yes
No
Secondary Work Site Location(s)*
* must provide value
Other Works Site Location
What is the title of your activity in Kenya?*
* must provide value
Please provide a short 1-2 paragraph description of the project activities you will engage in while in Kenya.*
* must provide value
Trainees are permitted to engage in existing research activities, i.e. faculty led projects with existing IRB/IREC approvals, under the supervision of their faculty mentors/supervisors. However, if you plan to initiate a new research activity, you will need to seek additional approval. AMPATH Policies and Procedures for Research Project and Grant Development . *
* must provide value
Yes No
Has your project been submitted to the Research Program Office for review?*
* must provide value
Yes No
All new AMPATH research projects are must complete AMPATH's standard working group and core review process before any project work can begin. Trainees who plan to conduct a new research project during their visit will be required to complete this approval process prior to their arrival and obtain any required human subjects approval from Moi University's Institutional Review and Ethics Committee (IREC) as well as IRB approval from their home institution. We recommend starting this process at least 16 weeks before your planned arrival to ensure there is no delay to the start of your project work.
STEP 1: REVIEW OUR POLICIES AND PROCEDURES If you're a Consortium member or partner submitting a proposal:
Review the Policies and Procedures for project development Contact the AMPATH Research Program Office with questions If you're a trainee:
STEP 2: SUBMIT A PROPOSAL If you're ready to submit a new study proposal for review, please complete the following process.
STEP 3: PROPOSAL REVIEW AND FEEDBACK
Routed to working groups and cores within 3 business days of submission Working groups and cores review for 4-6 weeks and provide feedback Upon approval, proposals are submitted for approval by Moi University's Institutional Review and Ethics Committee (IREC) Additional approvals may be required by partner institutional review boards * must provide value
Your answers to the following questions will assist us in determining what additional services or approvals your visit may require (e.g., medical licensing, scheduling assistance, etc.). Will you need assistance from AMPATH personnel in planning the programmatic itinerary for your visit?*
For guidance on travel and visit logistics, please see the AMPATH Kenya Logistics Manual . Please note that if your visit is approved, you will have the option to request housing and/or apply for a clinical license in the next forms.
* must provide value
Yes No Unsure
Please elaborate on what kind of planning assistance you may need, if known.
Clinical Licensing Any licensed clinician who plans to participate in clinical work , engage in patient management decisions , and/or serve as the clinical supervisor for a consortium clinical trainee must obtain a temporary clinical license prior to arrival in Kenya. At this time, this includes physicians, residents, fellows, pharmacists, nurses, and physician assistants. Do you plan to participate in any clinical work, engage in any patient management decisions, and/or serve as a clinical supervisor for an AMPATH Consortium clinical trainee during your visit?*
* must provide value
Yes No Unsure
Do you possess an active clinical license in a country outside of Kenya? (e.g., medical, nursing, PA, etc.)*
MEDICAL RESIDENTS: If you are currently in a medical residency program, please select yes.
* must provide value
Yes
No
In which field are you licensed? I am a:*
* must provide value
Nurse or Nurse Practitioner Pharmacist Physician Physician Assistant Physician (Resident/Fellow) Other
PERMIT REQUIREMENTS FOR NURSING STUDENTS Any nursing student who does not possess a nursing practice license (e.g., a registered nurse in a nurse practitioner program)
Nurse Practitioner (NP/ARNP) Registered Nurse (RN) Other
Other Nursing License Type
If your visit is approved, would you like to apply for a temporary clinical license?*
If you select yes, you will receive an email invitation with a link to start your application once your visit has been approved.
PLEASE NOTE: If you opt not to apply for a license, you will not be able to participate in any clinical work, engage in patient management decisions, nor serve as a clinical supervisor for an AMPATH Consortium clinical trainee. For questions about this, please contact the AMPATH Visitors Team .
* must provide value
Yes
No
Clinical Subspeciality (if applicable) :
Do you currently hold a specialty certification?* (e.g., emergency, oncology, etc.)
Please note that if you select 'Yes,' you will be required to upload a copy of your certificate below.
* must provide value
No
Yes (Please list in the space provided below)
Clinical Specialty (if applicable):
Permission to Apply for a Temporary License Due to updated requirements from the Government of Kenya (GOK), all foreign clinicians intending to participate in clinical work while in Kenya must obtain pre-approval from the GOK Cabinet Secretary of Health (CS) before they may apply for a temporary clinical license.
To receive pre-approval, our office must submit a copy of your passport bio-page, clinical license, relevant diploma, and board certificate (if applicable) to the CS at least three months in advance of your arrival.
Please note that once your visit has been approved, you will be prompted to submit additional documents via a separate survey.
To ensure that you may apply for a temporary license, please upload the following: Current Home Clinical License *
* must provide value
NURSES: Please note that this must be a digitally-verified copy of your current practicing license with current practice license number.
Relevant Academic Diploma* (e.g., medical school, nursing school, etc.)
* must provide value
Board Certificate (if applicable)
Please upload a scanned copy of your passport information page (jpg or PDF format only).*
A copy of your passport bio-page is required for application pre-approval from the Cabinet Secretary. Nursing students applying for a nursing student permit must also submit a copy of their passport bio-page.
Please note that your passport must be valid for six months after your return date from Kenya. Please review the expiration date on your passport information page to ensure that it meets this requirement.
* must provide value
VISA REQUIREMENTS FOR NURSES AND NURSING STUDENTS Please note that those applying for a temporary nursing practice license or nursing student permit MUST SELECT "CONFERENCE" as the purpose of their visit on their Kenya Electronic Travel Authorization application (replaced Kenya eVisa), which requires submission of an invitation letter. Once your visit has been approved, the AMPATH Visitors Team will email you an invitation letter based on the information you provide in this form.
NOTE: Please do not apply for your eTA until you have received this invitation letter.
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KENYAN CONTACT (ACTION REQUIRED): The name of a Kenyan contact or counterpart is required for your invitation letter.
Please return to the VISIT SUMMARY section above and enter the contact information for a Kenyan contact.
Do you possess a renewable, one-year medical license issued by the Kenya Medical Practitioners and Dentists Council (KMPDC)? (NOT COMMON)
PLEASE NOTE: The majority of returning physicians do not fall under this category, as temporary medical licenses issued since early 2020 are valid only for the dates of the applicant's visit. This license type is obtainable only via a Peer Review application or through a one-time application process in 2021 and requires you to maintain an online KMPDC account .
As renewal fees for this license type have increased significantly, this license type is now only recommended for long-term visitors. For others with current or expired one-year licenses, our office will seek an exception so you may apply for a short-term/temporary license.
Yes. I have a current, one-year medical license (NOT COMMON)
Yes. I have a one-year license through the KMPDC but have not renewed it for the current year (NOT COMMON)
No. I did not apply for registration in the KMPDC portal in 2021 nor did I complete a Peer Review through the KMPDC (MOST COMMON)
Based on the information you provided, your visit requires pre-approval from the following teams before you may proceed: AMPATH Education (required for all clinical activities) AMPATH Leadership Team The AMPATH Team will work to notify you as to whether your visit is approved within two weeks of form submission. You will be contacted in the meantime if any additional information is required for visit approval. For questions, please contact the AMPATH Visitors Team .
Based on the information you provided, your visit is tentatively APPROVED . Please submit this form to finalize your pre-approval. The AMPATH Visitors Team will contact you if additional information is required. Upon submission of this form, you will be prompted to begin the next form(s). Please make sure to submit all forms listed below no later than six weeks pre-departure. For questions, please contact the AMPATH Visitors Team.
Next Required Forms: Visitor Contact Information Form Required for all visitors Lodging at IU House may be requested via this form. Please note that no lodging requests will be considered confirmed without submission of this form. Clinical Licensing As a pharmacist, there is no temporary license application that you will need to complete; however, you will be required to submit copies of your pharmacy diploma and license in the Visitor Contact Information Form in order to access any clinical areas of the MTRH hospital campus.
Application for a Temporary Clinical License Required for any physician, nurse, or physician assistant who will need access to clinical areas of the Moi Teaching and Referral Hospital campus (for clinical or non-clinical purposes) Please make sure to submit this application no later than six weeks prior to arrival, as any clinician without an active Kenya license will not be permitted to enter clinical areas. Research Trainee Review Required
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Clinical Trainee Review Required
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Non-Clinical Trainee Review Required
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Home Institution Administrator First Name:
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Home Institution Administrator Last Name:
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Home Administrator Email:
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Discipline Lead First Name:
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Discipline Lead Last Name:
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Incomplete Review Form Email:
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Visit Request Status (ARCHIVED)
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Confirmed Canceled Tentative To Be Rescheduled
PDF of Visitor Pre-Approval Form
Today M-D-Y
Submit
Save & Return Later