Full Name as it appears on your Passport:
Specify profession or specialty:
Date of Birth:
Country of issuance:
Cell Phone Number in the following format (xxx)xxx-xxxx:
Alternate Phone Number in the following format (xxx)xxx-xxxx:
Which RVU sponsored trip will you be joining?
Date of departure:
Date of return:
If you are coming on the KENYA trip, which dates are you wanting to participate?
Emergency Contact Information
Name of Emergency Contact: (this should be a child or spouse or sibling, etc...)
Relationship to the Emergency Contact:
Phone Number for Emergency Contact in the following format (xxx)xxx-xxxx:
Email address for Emergency Contact:
Do you speak the language of the country to which you will be traveling?
What is your Shirt size?
Standard Protocol for a Needle Stick
If you are stuck by a needle or other sharp object or get blood or other potentially infectious materials in your eyes, nose, mouth or on broken skin, immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. Report the incident to your employer and seek immediate medical attention. Many employers have a procedural manual for steps to follow to guarantee that all risk-reducing steps are addressed. Notify the RVU Office of Clinical Affairs immediately.
Post-exposure Exam (can be done on site or after you return home)
During the first visit to a doctor following a needle stick, blood will be drawn to perform a baseline test, which checks for any virus or suspicious antibodies. Additional blood draws taken every 6 weeks, 12 weeks and 6 months after exposure check for activity of any viruses. Extended HIV follow-up (typically 12 months) is recommended for professionals infected with HCV after exposure to a source co-infected with both HIV and HCV. HIV testing should be performed on any exposed person who has an illness compatible with an acute retroviral syndrome, regardless of the interval since exposure.
Post-exposure prophylaxis (PEP)
According to the CDC, PEP is most effective if you take it within 2 hours of possible HIV exposure and should be taken for 3 days. At that time, you should consult your physician to see if you should take for a full 28 days. (Depends on risk level.)
Please refer to the attached tables from the CDC MMWR- September 5, 2005/Vol. 54/No.RR-9
You may be restricted of drug choice due to your location. The longer you wait to start PEP, the greater the risk of becoming HIV-positive. You may want to stop the rotation and make arrangements to come back to the US, especially if you are at High Risk for contracting infection.
The PEP for HBV is the Hepatitis B immune globulin and the HBV vaccine. You should already be vaccinated.
Post-exposure prophylaxis to prevent HIV infection
Fact sheet- 1 December 2014
Globally, there were an estimated 35 million people living with HIV, of whom 13 million were on antiretroviral treatment (ART) at the end of 2013.
People can be accidentally exposed to HIV though healthcare work or due to exposures outside healthcare setting, for example, through unprotected sex or sexual assault.
Antiretrovirals (ARVs) have been used to prevent infection in case of accidental exposures for many years. This intervention is called post exposure prophylaxis (PEP) and involves taking a 28-day course of ARVs.
PEP should be offered, and initiated as early as possible, for all individuals with an exposure that has the potential for HIV transmission, and ideally within 72 hours.
If started soon after exposure, PEP can reduce the risk of HIV infection by over 80%. Adherence to a full 28-day course of ARVs is critical to the effectiveness of the intervention.
Recent evidence shows PEP uptake has been insufficient: only 57% of the people who initiated PEP have completed the full course and rates were even lower at 40% for victims of sexual assault.
Why guidelines are needed
For many people that are accidentally exposed to HIV, PEP provides a single opportunity to prevent HIV after exposure. Such accidental exposures may be among health care workers who had needle stick injuries or among adults and children who survived sexual violence.
Access to timely PEP remains challenging in many settings in particular for non-health worker exposures (1l. Recent studies highlight the need to simplify approaches and improve the use of HIV PEP. Reported issues include, missed opportunities to provide PEP following sexual exposure in the United Kingdom !3l, lack of PEP protocols and limited compliance to guidance in China !4l, Nigeria !5) and UK !6), limited access to PEP by female sex workers in Kenya (7) and health workers in Uganda (B), and structural stigma that reduces PEP uptake among men who have sex with men in the United States of America !9)
Factsheet: post-exposure prophylaxis to prevent HIV infection
HIV topic: post-exposure prophylaxis
Use of antiretrovirals for treatment and prevention of HIV infection
By filling in your name here, you are signing this form electronically. You agree that your electronic signature is intended as your official signature on this form, and as such, is legally binding.
Full Legal Name:
Country of Travel:
Dates of Travel:
Release of Liability and Assumption of Risks for International Externship
THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISKS (the “Release”) is executed by the participant named in this registration packet in favor of ROCKY VISTA UNIVERSITY, a Colorado for profit corporation (the “University”), whose address is 8401 South Chambers Road, Parker, Co. 80112.
PARTICIPATION IN THE TRIP - I desire to participate in the global medical outreach trip to the country listed in this registration packet, As a student/volunteer I understand that I am not required, as part of my core academic program, work or otherwise, to participate in the Externship/Trip. This global experience, I undertake of my own free will.
WAIVER OF UNIVERSITY LIABILITY FOR DANGERS AND RISKS - I understand that there are certain dangers, hazards and risks inherent in international and national travel and the activities to be engaged in during the Externship/Trip including, but not limited to, those set forth in Exhibit “A” attached hereto and made part hereof, which can cause personal injury, death and/or property damage. I further understand that the University cannot and does not assume responsibility for any such personal injury, death or property damage.
ASSUMPTION OF RISKS- Notwithstanding the dangers, hazards and risks involved, and in consideration of being permitted to participate in the Externship/Trip:
DISCLAMER OF UNIVERSITY RESPONSIBILITY - I UNDERSTAND AND AGREE THAT THE University is:
RESPONSIBILITY FOR MEDICAL NEEDS - I represent to the University that I am aware of my personal medical needs and that there are no health related reasons or problems which may preclude or restrict my participation in the Externship/Trip. I acknowledge that the University has strongly recommended that I obtain medical insurance and evacuation coverage valid in the country of travel to protect against the cost of hospitalization and physician care in the event of sickness, accident, injury, disability, and medical evacuation. I understand that I am solely responsible for obtaining such insurance. I further understand and agree that (i) the University is not responsible for attending to any of my medical or medication needs, (ii) I assume all risks and responsibility for my medical and medication needs, and (iii) if I am required to be hospitalized at any time during the Trip, the University, does not assume any legal responsibility for payment of such costs.
EMERGENCY MEDICAL TREATMENT - I understand that the Releasees do not have medical personnel available at any time during the Externship/Trip. I grant the Releasees permission to authorize my emergency medical treatment, including surgery, in the event that I am unable to do so. I acknowledge and agree that this grant of authority does not create a special relationship between the University and me. I further acknowledge and agree that Releasees assume no liability or responsibility for any injury or damage I may suffer or incur arising out of or in connection with such authorized emergency medical treatment.
LEGAL PROBLEMS – I understand that if I have legal problems in the country to which we are traveling during the trip, I will attend to the matter personally with my own funds and that the University is not responsible for providing any assistance to me under such circumstances.
BINDING NATURE OF RELEASE – It is my express intent that this Release shall bind the members of my family (including my spouse, if any) if I am alive, and my heirs, personal representatives, successors and assigns if I am deceased.
INDEMNIFICATION – I agree to indemnify, defend and hold the Releasees harmless from any liability, claim, action, debt, damage, loss, cost and expense of every kind or nature asserted by any party against any Releasee or incurred by any releasee and arising directly or indirectly from or in connection with my participation in the Externship/Trip or any of the activities I engage in during the Externship/Trip.
RESERVATION OF RIGHTS- I acknowledge that the University reserves the following rights that it may exercise in its sole discretion: (i) the right to cancel the Externship/Trip, and (ii) the right to make alterations, changes and modifications in any part of the Externship/Trip itinerary and the activities in connection therewith.
PASSPORT, VISA AND VACCINATIONS – I understand that am responsible for obtaining my own passport, visa and public health vaccinations.
COMPLIANCE WITH LAWS- I agree to comply with all laws of the country to which we are traveling during the Externship/Trip.
DISCLOSURE – THE UNIVERSITY HAS INFORMED ME THAT BY SIGNING THIS DOCUMENT I RELEASE AND WAIVE LEGAL RIGHTS THAT I OTHERWISE MIGHT HAVE, AND THAT I SHOULD READ THE DOCUMENT CAREFULLY AND UNDERSTAND IT FULLY BEFORE SIGNING.
1. REPRESENTATIONS – I represent to the University that (i) I have read this Release and fully understand its content and the effect of its terms and provisions, (ii) I sign this Release as my own free act and deed, (iii) with respect to the matters set forth in this Release, no oral representations, statements or inducements other than those expressly contained herein have been made to me by any of the Releasees, (iv) I am over the age of eighteen (18) and fully competent to sign this Release, and (v) I execute this Release for complete and adequate consideration, fully intending to be bound by the same.
2. GOVERNING LAW – I agree that this Release shall be construed in accordance with the laws of the state of Colorado.
3. PARTIAL INVALIDITY – If any provision of this document shall be held illegal or unenforceable, then I agree the validity of all remaining provisions shall not be affected thereby to the maximum extent permitted by law.
Problems and Hazards that participants may experience include but are not limited to:
Release of Liability Form - TSP Dept. Policies and Procedures Appendix A - June 10, 2022
I have read in full the information in this registration packet and understand the requirements to participate in this rotation/trip. I will comply with these requirements so I can be eligible to receive Clinical Education Rotation/Elective Credits for my time spent abroad.
Name of participant:
Name as it appears above: