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General Informations

Email Address

First Name

Last Name

Date of Birth

Gender

Nationality

Passport number/Identity card number

Expired date of your passport

Phone number

Your address in your home country

Home Institution

University name

Faculty/Program

Current study year

Hospital Locations

Kindly indicate your preferred host hospital for internship placement. Otherwise, your host hospital will be assigned based on hospital availability at the time of placement.

Which hospital in our allied system do you prefer to be placed in?*

Tam Tri General Hospital in Da Nang
Address: 64 Cach Mang Thang 8 St., Khue Trung Ward, Cam Le Dist, Da Nang City, Vietnam
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Phan Chau Trinh University Hospital
Address: 09 Nguyen Gia Thieu St., Dien Ngoc Ward, Dien Ban Town, Quang Nam Province, Vietnam
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Which hospital in our allied system do you prefer to be placed in?

Da Nang Tam Tri General Hospital

Phan Chau Trinh Medical University Hospital

Tam Tri Da Nang General Hospital

Preferred departments at Phan Chau Trinh Medical University Hospital:

Note: Please select the number of clinical departments, not exceeding the number of internship weeks.*

Which clinical department do you like to undertake your rotation?

Internal Medicine

Surgery

Obstetrics & Gynecology (OB/GYN)

Pediatrics

Ophthalmology

Otolaryngology (ENT)

Anesthesiology & Intensive Care

Dermatology

Traditional Medicine

Dentistry

Diagnostic Imaging (or Radiology)

Emergency Department (ED)

Phan Chau Trinh Medical University Hospital

Preferred departments at Phan Chau Trinh Medical University Hospital:

Note: Please select the number of clinical departments, not exceeding the number of internship weeks.*

Which clinical department do you like to undertake your rotation?

Internal Medicine

Surgery

Obstetrics & Gynecology (OB/GYN)

Pediatrics

Ophthalmology

Dermatology

Dentistry

Other

If other, please specify

Elective Details

Elective duration (Unit: week)

Start Date of Your Rotation

End Date of Your Rotation

LEARNING GOALS AND OBJECTIVES *

Tell us what you hope to learn from this shadowing experience.

This statement will help to design a well-rounded clinical experiences for you.

This information will be used by or disclosed for the purpose of job shadowing.

For question, concerns or more information about the collection, use or disclosure of your personal information, please contact the International Collaboration Center by email at ged@pctu.edu.vn

LEARNING GOALS AND OBJECTIVES

Supporting Information

Curriculum Vitae (short version) stamped by home university/institution

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Passport face page scan

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Contact us

Tel: +84 0235.757.959
E-mail: ged@pctu.edu.vn
Address: No.09 Nguyen Gia Thieu St., Dien Ban Dong Ward, Da Nang City, Vietnam
Monday – Saturday
7h30-11h30am ; 12h30-4h30pm (GMT+7)
GED office hours at Phan Chau Trinh University Campus