HEALTH PROFESSIONS EVALUATION (HPE) – …



|Name:       |BIOGRAPHICAL FORM |Date: 10/30/2014[pic]10/30/2014 |

Before completing this form, carefully read the Sample Biographical Form. All forms must be typed.

To complete Section XIV, you will need an official or unofficial transcript from each college you attended.

Sections 1-3 are for the HPAC. Keeping the HPAC apprised of changes to this information will prevent delays in your evaluation process.

I. BACKGROUND INFORMATION

TSU student ID#:       telephone #:       e-mail:      

If your are Pre-Med, -Dent, or -Vet and have registered with TMDSAS, what is you TMDSAS #:      

From what high school did you graduate (include city and state)?      

What was your rank in your high school graduating class?      

What was your score on college entrance exams? SAT       ACT      

When was your first semester at TSU?      

Are you a degree-seeking student at TSU?

If yes, what is your major?       What is your concentration?      

If a degree seeking student, in which semester and year do you expect to graduate?      

What is your current GPA?       Science GPA (BIOL, CHEM, PHYS, MATH)?      

How many hours did you complete in the semester of your heaviest course load?      

Professional program to which you are applying: If other, please specifiy:      

I am applying to enter professional school in the fall of 20     .

Have you previously applied to professional school? If yes, when?      

Native language English? Other fluent languages:      

U.S. citizen? If no, country of citizenship:      

Ethnicity:

Have you completed a professional school admissions test? Which exam?

If yes, when did you take this exam?       If no, when do you plan to take it?      

If you completed a professional school admissions test, please enter your scores in the appropriate boxes below.

• MCAT: verbal reasoning       physical sciences       biological sciences       writing      

• DAT: AC AVG     PAT      QRT     RC     BIOL      GEN CHEM     ORG CHEM     TOTSCI     

• PCAT: VERB       RCT       BIOL       CHEM       MATH       TOT       %TOT      

• GRE: QUANT       VER       TOT      

Briefly describe how you prepared for or are planning to prepare for your professional school admission test.

     

II. COLLEGES, UNIVERSITIES, and PROFESSIONAL SCHOOLS

Indicate in all colleges/universities you have attended as well as applicable dates of attendance:

|College |Dates Attended |Degree Earned |Major |

|(Begin with the earliest) |From To |(if yes, give date) |(if applicable) |

|      |      /      |      |      |

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|      |      /      |      |      |

III. YOUR EVALUATORS

HPE participants must solicit 3-5 letters of evaluation, including two from professors.

|Evaluator Name |Position |Relation to You |

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Sections IV-XIII mimic the TMDSAS application. Fill in each section thoroughly, but try to conserve words. Refer to the sample document for examples and detailed instructions.

IV. ACADEMIC RECOGNITION

Describe any academic honors, awards, and other recognitions received since beginning college to the present.

|Activity/Honor |Description of Activity/Honor |Date Awarded |

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V. LEADERSHIP EXPERIENCE

Describe any leadership roles or positions of responsibility held since beginning college to the present.

|Role Title |Description of Responsibilities |Dates |

| |(including “hours/week” and “hours total”) |From To |

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VI. RESEARCH EXPERIENCE

Describe any significant research activities you have participated in since beginning college.

|Role Title |Supervisor |Dates |

|(include your responsibilities, “hours/week” and “hours total”) | |From To |

|      |      |      /       |

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VII. HEALTHCARE RELATED EXPERIENCES

Any activity in which you worked with or observed patients or health professionals is “health care related.”

Describe any such experiences that you participated in since beginning college.

|Activity |Description |Dates |

| |(including “hours/week” and “hours total”) |From To |

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VIII. COMMUNITY SERVICE

Describe any non-healthcare related community service or volunteer experience that you participated in since you began college.

|Activity |Description |Dates |

| |(including “hours/week” and “hours total”) |From To |

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IX. EXTRACURRICULAR/LEISURE ACTIVITIES

Describe any extracurricular or leisure time activities to which you devoted significant time since you began college.

|Activity |Description |Dates |

| |(including “hours/week” and “hours total”) |From To |

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X. EMPLOYMENT EXPERIENCES

Describe any paid jobs that you have held since you began college.

|Job Title |Where Employed and Responsibilities |Dates |

| |(including “hours/week” and “hours total”) |From To |

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XI. ACADEMIC DISHONESTY AND/OR CRIMINAL ACTIVITY

Describe any actions taken against you for academic dishonesty, conduct violations, criminal activity (including felony and/or misdemeanor, other than minor traffic violations). Be as brief as possible while including relevant details and applicable dates.

     

XII. PERSONAL STATEMENT/APPLICATION ESSAY - required

This question mimics the TMDSAS Personal Statement Essay.

Explain your motivation to seek a career in (field/discipline to which you are applying). Discuss your philosophy of the profession and indicate your goals relevant to the profession. Limit your response to 5000 characters.

     

XIII. UNIQUE LIFE EXPERIENCES -required

This question mimics one of the TMDSAS Optional Essay prompts.

Briefly discuss any unique circumstances or life experiences that are relevant to your professional school application which have not been previously presented. Limit your response to 2500 characters.

     

XIV. PERSONAL CHARACTERISTICS FOR DIVERSITY - required

This question mimics one of the TMDSAS Optional Essay prompts.

Describe any personal characteristics and/or important challenging experiences you have had that will contribute to the diversity of or provide educational benefits to the medical/dental student body. Limit your response to 2500.

     

• XVI. TRANSCRIPT and CHRONOLOGICAL SUMMARY

For each box, write the names of activities that you listed above.

|DO note how many hours per week or month that you participated in each activity. |DO denote any series of one-time events (i.e. “community service through AED”) |

|DO use abbreviations wherever you can do so clearly. |DO NOT denote one-time events separately |

|DO note where you took each class, if NOT at Tarleton State University. |DO NOT list an activity in more than one column, even if you listed it in more than one section above. |

| |Instead, choose whichever column below is most appropriate. |

|DO include the letter grade for each class you took. | |

If you entered activities in the Leadership section of the Biographical Form, include them in the chart below. Choose whichever column best matches each activity.

|Sem |school |Classes |Cred |GPA |Healthcare or Research |Other Extracurricular |Employment |

| | | |hrs | | | | |

|F'05 |UTD |C Chem I & lab A |14 |3.57 |      |Helped w/ billing for dad’s med. practice, 4 |      |

| | |A Macroecon. | | | |hr/month | |

| | |A Col. Algebra | | | |Bollywood dance, 2 hr/wk | |

| | |A RHET 1101 | | | |Community service, 22 hrs | |

| | |A RHET 1302 | | | | | |

|S'06 |UTD/CCCC |A Intro. Mgmt. Acct. |13 |3.77 |      |Helped w/ billing for dad’s med. practice, 4 |      |

| | |B Chem II & lab A | | | |hr/month | |

| | |A Precalculus | | | |Bollywood dance, 2 hr/wk | |

| | |A Dance Apprec. (CCCC) | | | | | |

|U'06 |SMU |A Am. Govt. (SMU) |6 |4.00 |      |Helped w/ billing for dad’s med. practice, 4 |      |

| | |A U.S. Hist. (SMU) | | | |hr/month | |

| | | | | | |Bollywood dance, 2 hr/wk | |

|F'06 |UTD/CCCC |A Bio I & wksp |13 |3.70 |      |Helped w/ billing for dad’s med. practice, 4 |Receptionist, home healthcare agency, 5 hrs/wk |

| | |B O.Chem I & lab A | | | |hr/month | |

| | |A Calc I (CCCC) | | | |Bollywood dance, 2 hr/wk | |

|S'07 |UTD |A Intro. Fin. Acct. |15 |4.00 |      |Helped w/ billing for dad’s med. practice, 4 |Receptionist, home healthcare agency, 12-15 hr/wk |

| | |A Bio II & wksp | | | |hr/month | |

| | |A O.Chem II & lab A | | | |Bollywood dance, 2 hr/wk | |

| | |A Calc II (CCCC) | | | |Young Muslims of North America, 4 hr/wk | |

|U'07 |UTD |A Phys for Bios. I & lab |4 |4.00 |      |Helped w/ billing for dad’s med. practice, 4 |Receptionist, home healthcare agency, 12-15 hr/wk |

| | | | | | |hr/month | |

| | | | | | |Bollywood dance, 2 hr/wk | |

| | | | | | |Young Muslims of North America, 4 hr/wk | |

|F'07 |UTD/CCCC |A Biochem I & wksp |11 |4.00 |      |Helped w/ billing for dad’s med. practice, 4 |Assistant Manager, home healthcare agency, |

| | |A Phys for Bios. II & lab | | | |hr/month |20 hr/wk |

| | |A World relig. (CCCC) | | | |Bollywood dance, 2 hr/wk | |

| | | | | | |Publicity Comm Chair, Young Muslims, 4 hr/wk | |

|S'08 |UTD |A Fin. Info. Mgmt. |12 |4.00 |Volunteer, nursing home, 8 hr/month since 3/08 |Helped w/ billing for dad’s med. practice, 4 |      |

| | |A Organizaton Behavior | | | |hr/month | |

| | |A Bio lab | | | |Bollywood dance, 2 hr/wk | |

| | |A Biochem II & wksp | | | |Publicity Comm Chair, Young Muslims, 4 hr/wk | |

| | | | | | |High school tutor, 3 hr/wk | |

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