Ucla Prime Medical Student Program

UCLA PRIME MEDICAL STUDENT PROGRAM

Supplemental Information Form

2015-2016

Upon email notification that you have been invited to submit a Supplemental Information Form,please submit the followingitems as instructed.

UCLAPRIME
DavidGeffenSchool of Medicine at UCLA

10833 Le Conte Avenue

Dean’s Office CHS 12-159

Los Angeles, CA90095-1720

We require TWO2x2professionalpassport pictures of your head and shoulders with white
background(photos should be obtained at Costco, Rite Aid, CVS, etc). Both photos must be mailed to the UCLA PRIME address listed above. Please write your name and AMCAS ID number on the back of each picture.Please do not take these pictures yourself. These photos will be used for interviewers if you are invited for an UCLA PRIME interview, please dress professionally.

An$80.00 fee using a credit card via the Supplemental Fee link on your Admissions
Status webpage.It is payable by Visa, Master Card, or Discover or debit card.
If you are eligible for a Fee Waiver, the Admission Status Information webpage will
inform you.

A completed Supplemental Information Form to be emailed to our UCLA PRIME office as a doc or pdf document at

Supplemental Information Form includes the following items:

UCLA PRIME Supplemental Information Form (page 1)
Prerequisites to Matriculation (page 2)
Activities information (page 3)
Contact Information (page 4 )
Supplemental Essay Questions (pages 5-8)
Letters or Recommendation Form (page 9)
Disadvantaged additional information (if applicable, please only fill this out if you identified yourself as a disadvantaged applicant on AMCAS) pages 10-12
Letters of recommendation must be uploaded to the AMCAS letter service.

LEGAL LAST NAME: / LEGAL FIRST NAME: / MIDDLE NAME:
AMCAS ID: / TELEPHONE (Home): / TELEPHONE (Cell):
PERMANENT ADDRESS (City, StreetState, Zip): / STATE OF LEGAL RESIDENCE: / EMAIL:

Each UCLA PRIME class has 2 programs. Please identify which program(s) you are interested in. For more information about the programs please visit our website at

PRIME UCLA-CDU / PRIME UCLA-Westwood
Applicant Name: / AMCAS ID#:

PREREQUISITES FOR MATRICULATION

Please provide information on your prerequisites for matriculation below:

Subject / Course Number / Course title / Completion
Code* / Final
Grade
English
One year of college English to include the study of English composition
Physics
One year of college Physics (with equivalent lab)
Chemistry
Two years of college chemistry to include the study of inorganic chemistry, quantitative analysis and organic chemistry (with lab)
Biology
One year of general biology (with equivalent lab)
Mathematics
One year of college mathematics to include the study of introductory calculus and statistics

*Code as indicated

C =Course complete

IP =Course in progress

PT= Course(s) applicant plan to take (please provide date of expected completion)

Applicant Name: / AMCAS ID#:

ACTIVITIES

Please provide a list of those activities that were most important to you in terms of developing your academic, social and overall personal growth. Please list those activities as indicated below. Limit your responses to the space provided.

Community Leadership Activities:

Activity / Dates / Hr/Wk / Summer
Only

School Leadership Activities:

Activity / Dates / Hr/Wk / Summer
Only

Clinical Related Activities:

Activity / Dates / Hr/Wk / Summer
Only

Research Activities:

Activity / Dates / Hr/Wk / Summer
Only
Applicant Name: / AMCAS ID#:

Contact Information

Please provide the following information:

ALTERNATE CONTACT / INFORMATION
NAME OF CONTACT
RELATIONSHIP (family, friend, etc.)
CURRENT PHONE
WORK PHONE
CELL PHONES
E-MAIL ADDRESS
ALTERNATE CONTACT / INFORMATION
NAME OF CONTACT
RELATIONSHIP (family, friend, etc.)
CURRENT PHONE
WORK PHONE
CELL PHONES
E-MAIL ADDRESS

If you are planning to travel abroad during the application process please provide us with the months you will abroad and the best way to contact you. Please note that we can not speak to family members about your application.

Applicant Name: / AMCAS ID#:

DavidGeffenSchool of Medicine at UCLA

UCLA PRIME

Supplemental Essay Questions

Essay Question #1: What is the most important health care issue confronting disadvantaged communities and what would be your first steps to address this issue?

Please answer the following question as completely as possible, limiting your response to the space provided (2,000 characters with spaces, font size 11, Times New Roman).

Applicant Name: / AMCAS ID#:

DavidGeffenSchool of Medicine at UCLA

UCLA PRIME

Supplemental Essay Questions

Essay Question #2:In what way will graduating from the UCLA PRIME program enhance your career in health care or health services for the disadvantaged communities?

Please answer the following question as completely as possible, limiting your response to the space provided (2,000 characterswith spaces, font size 11, Times New Roman).

Applicant Name: / AMCAS ID#:

DavidGeffenSchool of Medicine at UCLA

UCLA PRIME

Supplemental Essay Questions

Essay Question #3:Describe the manner in which your experiences demonstrate your understanding of, and commitment to, underserved communities.

Please answer the following question as completely as possible, limiting your response to the space provided (2,000 characterswith spaces, font size 11, Times New Roman).

Applicant Name: / AMCAS ID#:

DavidGeffenSchool of Medicine at UCLA

UCLA PRIME

Supplemental Essay Questions

Essay Question #4:What are your greatest strengths and your greatest challenges as you approach medical school?

Please answer the following question as completely as possible, limiting your response to the space provided (2,000 characterswith spaces, font size 11, Times New Roman).

UCLA PRIME MEDICAL STUDENT PROGRAM

2015 - 2016

Applicant Name: / AMCAS ID#:

LETTERS OF RECOMMENDATION FORM

Three letters of recommendation will be required for the UCLA PRIME program. One letter from a science faculty member who can evaluate an applicant’s academic ability based on interaction from a science class taken. The second letter should be from a letter writer who can speak to the applicant’s leadership qualities. The third letter writer should be from a letter writer who can address other qualities or abilities the applicant would like to convey to the UCLA PRIME Admissions Committee. Please do not submit more than three letters unless your school is part of a letter service that sends all letters that are part of your file. We do not accept committee letters as one of our three letters of recommendation. UCLA PRIME participates in the AMCAS letter service. Please include this form to indicate the three letter writers you have selected for the UCLA PRIME application. Please note: ALL LETTERS MUST BE SUBMITTED ELECTRONICALLY THRU AMCAS.

Letter
Submitted by / AFFILIATION / Relationship to applicant / Letter type
1. / Science Professor Letter
2. / Leadership Letter
3.
Applicant Name: / AMCAS ID#:

Supplemental Disadvantaged information– (please fill out if you identified yourself as a disadvantaged student).

FAMILY INFORMATION:

Name / Highest
Level of Education / Occupation*
FATHER
MOTHER
GUARDIAN
STEP-PARENT
STEP-PARENT
BROTHER(S)**
SISTER(S)**
SPOUSE
Age / Current Address, City & State
FATHER
MOTHER
GUARDIAN
STEP-PARENT
STEP-PARENT
BROTHER(S)**
SISTER(S)**
SPOUSE

*Indicate whichever applies; primary occupation, disabled, unemployed, on social security, retired, deceased, etc.

**If you have more then two siblings please provide their information on a separate sheet of paper.

Applicant Name: / AMCAS ID#:

Supplemental disadvantaged status form - continued

Parent’s martial status: Indicate if single, married, divorced, remarried, deceased and/or widowed during the following ages:

Ages 1-5 / Ages 6-11 / Ages 12-17 / 18 to Present
FATHER
MOTHER

Predominant language(s) spoken at home as you grew up:

Ages 1-5 / Ages 6-11 / Ages 12-17 / 18 to Present

Estimated parental income during each period as you grew up:

Ages 1-5 / Ages 6-11 / Ages 12-17 / 18 to Present
BELOW $10,000
$10,00 - $20,000
$20, 001 - $30,000
$30,001 – $40,000
$40,001 - $50,000
OVER $50,000

Have you or members of your immediate family ever used federal or state assistance programs?

Yes / No / Don’t know / Decline to answer

How is your undergraduate education being financed? (Check all that apply):

FRESHMEN / SOPHOMORE / JUNIOR / SENIOR / POSTBACC/
Graduate
PARENTS
SELF-SUPPORTING
FINANCIAL AID
OTHER (PLEASE SPECIFY
Applicant Name: / AMCAS ID#:

Supplemental disadvantaged status form - continued

Applicant’s Employment:

List jobs held and number of
hours per week / Your
Age / Self-
Supporting
(Check) / Did you contribute to
the support of your
Family (Check)
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No
Yes No / Yes No

Demographic information: The following information addresses your family’s living situation during your formative and current years.

What type of community did you live in? Please check your community.

Ages 1-5 / Ages 6-11 / Ages 12-17 / 18 to Present
RURAL
INNER CITY/LOW INCOME
OTHER

Housing/Residence: Check any that apply:

Ages 1-5 / Ages 6-11 / Ages 12-17 / 18 to Present
PUBLIC
RENTED BY FAMILY
OWNED BY FAMILY
HOMELESS
OTHER