Project Form Submission

Welcome to the Office of International Medicine Programs (IMP), International Activities Database. This database will serve as a comprehensive repository of information about all of the international projects and activities taking place at the GW School of Medicine and Health Sciences (SMHS). This database is regularly used by GW leadership to stay up-to-date on international projects occurring across the globe. Such information provides a benefit to you as well in terms of the existence of an accurate and current database from which to draw when visiting various countries. In addition, the database provides a venue for showcasing the important work you are engaged in globally.

Please provide the following information on all of your international activities and projects across the globe to include any lectures or presentations given, collaborative research, missions, etc. Any questions regarding this effort may be directed to (impinfo@gwu.edu). Thank you in advance for your help.

* indicates a required field.

Faculty Information
* First Name
* Last Name
* Title
* Department
Collaborating Departments (if applicable)
* Phone
* Email Address

International Project/Activity (current/ongoing or in development)
Please complete a separate entry for every project/activity you are participating in abroad whether it is current/ongoing or in development. Projects or activities can include: lectures or presentations given; collaborative research; missions; site visits; etc.
* Project Title
* Scope/Description
If the international activity you are entering spans across multiple regions, please select "Global" as the region of your activity. If your international project spans multiple countries within the same region, please select the region, and then indicate in the spaces provided the countries and if applicable, cities involved in your international activity.
* Region	Please Select Asia Australia, New Zealand, and Oceania Central America, South America, and Caribbean Europe Global Middle East and North Africa Sub-Saharan Africa U.S., Canada, and Mexico
* Country One	Please Select Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the (DRC) Congo, Republic of the Costa Rica Cote d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, South Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Kitts and Nevis St. Lucia St. Vincent and the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
* City One
Country Two	Please Select Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the (DRC) Congo, Republic of the Costa Rica Cote d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, South Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Kitts and Nevis St. Lucia St. Vincent and the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
City Two
Country Three	Please Select Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the (DRC) Congo, Republic of the Costa Rica Cote d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, South Kosovo Kuwait Kyrgyz Republic Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Kitts and Nevis St. Lucia St. Vincent and the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe
City Three

Affiliated/Partnering Institution
* Are you working with an affiliated/partnering institution on this project/activity?	Please Select Yes No

* Affiliated/Partnering Institution
First Name
Last Name
Title
Phone
Email Address
Website
Additional Notes

Additional Information
* Is this project funded, IRB research, or have a legal agreement?	Please Select Yes No

Project/Contract/Proposal Number
IRB Number
Project Sponsor
Type of Agreement
Effective Date of Agreement
Expiration Date of Agreement

Project Achievements
* Do students, residents, fellows, other GW faculty and staff, or international scholars participate in this project/activity?	Please Select Yes No

Number of GW students participated
Number of GW residents and fellows
Number of international students participated
Number of GW faculty participated
Number of international faculty participated
Number of visiting scholars
Number of GW staff members participated
Number of employees working in country
Additional achievements

* Does the project/activity generate funds?

Please Select Yes No

Money generated
Additional achievements

* Were joint research articles published?

Please Select Yes No

Number of joint publications
Additional achievements

* Were courses or workshops offered?

Please Select Yes No

Number of courses offered
Number of certificates given
Number of events and workshops
Additional achievements

Project Timeline
* Project Start Date
Project End Date
If the project does not have an end date is this an on-going project?	Please Select Yes No

After review by the Office of International Medicine Programs (IMP), the following information will be included in the public version: Location of project, Affiliated Institutes, Title and Scope of Project, and Point of Contact at GW.