Tarleton Health Professions Advisory Committee (THePAC)

Name: / BIOGRAPHICAL FORM / Date: 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 AVGPAT QRTRCBIOL GEN CHEMORG CHEMTOTSCI

·  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
(Begin with the earliest) / Dates Attended
From To / Degree Earned
(if yes, give date) / Major
(if applicable)
FSpSm / FSpSm
FSpSm / FSpSm
FSpSm / FSpSm
FSpSm / FSpSm
FSpSm / FSpSm

III. YOUR EVALUATORS

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

Evaluator Name / Position / Relation to You

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
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr
FSpSmr


V. LEADERSHIP EXPERIENCE

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

Role Title / Description of Responsibilities
(including “hours/week” and “hours total”) / Dates
From To
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VI. RESEARCH EXPERIENCE

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

Role Title
(include your responsibilities, “hours/week” and “hours total”) / Supervisor / Dates
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
(including “hours/week” and “hours total”) / Dates
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
(including “hours/week” and “hours total”) / Dates
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
(including “hours/week” and “hours total”) / Dates
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
(including “hours/week” and “hours total”) / Dates
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.

Tarleton Health Professions Biographic Data Form

(10/30/2014) – Page 5 of 6

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 hrs / GPA / Healthcare or Research / Other Extracurricular / Employment
F'05 / UTD / C Chem I & lab A
A Macroecon.
A Col. Algebra
A RHET 1101
A RHET 1302 / 14 / 3.57 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Community service, 22 hrs
S'06 / UTD/CCCC / A Intro. Mgmt. Acct.
B Chem II & lab A
A Precalculus
A Dance Apprec. (CCCC) / 13 / 3.77 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
U'06 / SMU / A Am. Govt. (SMU)
A U.S. Hist. (SMU) / 6 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
F'06 / UTD/CCCC / A Bio I & wksp
B O.Chem I & lab A
A Calc I (CCCC) / 13 / 3.70 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk / Receptionist, home healthcare agency, 5 hrs/wk
S'07 / UTD / A Intro. Fin. Acct.
A Bio II & wksp
A O.Chem II & lab A
A Calc II (CCCC) / 15 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Young Muslims of North America, 4 hr/wk / Receptionist, home healthcare agency, 12-15 hr/wk
U'07 / UTD / A Phys for Bios. I & lab / 4 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Young Muslims of North America, 4 hr/wk / Receptionist, home healthcare agency, 12-15 hr/wk
F'07 / UTD/CCCC / A Biochem I & wksp
A Phys for Bios. II & lab
A World relig. (CCCC) / 11 / 4.00 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Publicity Comm Chair, Young Muslims, 4 hr/wk / Assistant Manager, home healthcare agency,
20 hr/wk
S'08 / UTD / A Fin. Info. Mgmt.
A Organizaton Behavior
A Bio lab
A Biochem II & wksp / 12 / 4.00 / Volunteer, nursing home, 8 hr/month since 3/08 / Helped w/ billing for dad’s med. practice, 4 hr/month
Bollywood dance, 2 hr/wk
Publicity Comm Chair, Young Muslims, 4 hr/wk
High school tutor, 3 hr/wk

Tarleton Health Professions Biographical Form

(10/30/2014) – Page 6 of 6