2016 COMMITTEE LETTER SELF-APPRAISAL FORM REFER TO THE INSTRUCTIONS FOR THE SELF-APPRAISAL FORM WHEN WORKING ON THIS DOCUMENT. BEFORE YOU BEGIN Carefully consider whether this is the best year for you to ask for a committee letter. By submitting this form, I attest that: My answers on the Preliminary Self-Assessment Form have confirmed that this is the best year for me to ask for a Committee Letter. PART I. BIOGRAPHICAL INFORMATION Legal Name for Application Name you prefer (if different) CU ID# Contact: Phone # Email address State of Residency for application Applying to (choose all that apply): MD / DO / DDS / OD / DPM / Dual Degree (Specify type) Previous Applications to Professional Schools, listed by year Previous Committee Letter Interviews, listed by year Languages Spoken, with level of proficiency (please indicate which language you speak at home): 1. 2. If you speak more than two languages, please continue the list below: Disadvantaged Status: Do you believe you qualify for disadvantaged status? If so, indicate the criteria below that pertain to you (check all that apply): First-generation college student (at a four-year institution) Growing up in a medically underserved community Family participation in state and federal assistance programs Attending college on a Pell Grant 1 PART II. ACADEMIC INFORMATION COLLEGES ATTENDED Inclusive Dates (Mo/Yr Mo/Yr) Name of College/University Degree Planned/Awarded (i.e. BA, MS, etc.) Minor(s)/ Certificate(s) Major(s) 1. 2. 3. 4. If you have attended more than four schools, please continue the list below: STANDARDIZED TESTS Have you taken the MCAT, DAT, or OAT? Yes No If you plan to take (or retake) the MCAT, DAT, or OAT in the future, indicate when: Most recent Test Scores: Old MCAT Date VR PS BS WS Total Date Chem/ Phys CARS Bio/ Biochem Psyc/ Socy Total Date PAT Quant Reas Read Comp Bio Gen Chem Date NatSci Read Comp Phys Quant Reas Total 1. 2. New MCAT 1. 2. DAT 1. 2. OAT 1. 2. O Chem Tot Sci Ac Avg GPA CALCULATIONS Undergraduate Year BCPM GPA BCPM Hours All Other GPA n/a AP/IB All Other Hours Total GPA n/a Total Hours n/a HS FY SO JR SR Postbaccalaureate (all undergrad-level courses taken after graduation) Postbacc BCPM GPA Postbacc BCPM Hours Postbacc All Other GPA Postbacc All Other Hours Postbacc Total GPA Postbacc Total Hours Cumulative Undergraduate (all undergrad-level courses taken, including before and after graduation) Cumulative Undergrad BCPM GPA Cumulative Undergrad BCPM Hours Cumulative Undergrad All Other GPA Cumulative Undergrad All Other Hours Cumulative Undergrad Total GPA Cumulative Undergrad Total Hours Graduate (all courses taken at the 5000-level, whether on your own or in a formal grad school program) Graduate BCPM GPA Graduate BCPM Hours Graduate All Other GPA Graduate All Other Hours Graduate Total GPA Graduate Total Hours If your Cumulative Undergraduate GPA (BCPM and/or Total) is below 3.3, you are not eligible for a Committee Letter unless your petition for a waiver is approved. If you have not done so already, go to Committee Letters> Eligibility and submit a GPA Petition ASAP. PART III. WORK AND ACTIVITIES Using the template below (copy and paste as needed), organize your relevant experiences into the following categories, arranging them in reverse chronological order (most recent first) within each category. (Refer to the Self Appraisal Instructions for more information on this section.) HEALTHCARE ACTIVITIES RESEARCH ACTIVITIES DIRECT SERVICE TO OTHERS (EITHER PAID OR VOLUNTEER) HONORS, AWARDS, SCHOLARSHIPS OTHER PAID EMPLOYMENT LEISURE ACTIVITIES Experience Name Start date (mo/yr) to end date (mo/yr) Average hours/week Total hours, to date Paid or volunteer? Organization Name Contact Name, Title, and Email address Experience Description (1325 characters, maximum) 4 PART IV. REFLECTION QUESTIONS 1. Describe a particularly meaningful insight you have gained during your clinical experiences. 1,325 character max 2. How do you know you want a career focused on service? 1,325 character max 3. What aspect of your college (or graduate school, if applicable) career did you find most intellectually exciting? 1,325 character max 4. Healthcare providers must provide care to all patients. Tell us about a time when you gained insight into the challenges faced by someone whose life experiences have been different from yours and what you learned from that experience. 1,325 character max 5. Name a topic you have encountered outside of a course that you decided to learn more about. Explain how you went about gathering information, what you learned, and what the experience meant to you. 1,325 character max 6. What experience have you had leading and/or motivating large or small groups of people? How would you describe your personal approach to effective leadership? Think about leadership in broad terms that include not only managerial positions or offices you may have held, but also experiences such as tutoring and mentoring others. 1,325 character max 7. What are your plans for the upcoming year (spring 2016 to spring 2017) and how will they help you continue to develop as an applicant? 1,325 character max 8. Briefly list two ethical topics you are likely to confront as a healthcare professional. You should feel well informed on each topic, be able to discuss different points of view, and if you have an opinion, be able to back it up with evidence. You are likely to be asked to discuss one of these topics at your Committee Letter Interview. Limit your answer to no more than one line per topic. a. b. 9. Be prepared to answer questions at your Committee Letter Interview about healthcare reform in the United States and to clearly state the goals of the Affordable Care Act. (Do not write out your answer here.) 5 PART V. OPTIONAL QUESTIONS These are truly optional. They provide space for you to tell us about something that did not fit anywhere else in the materials you provide to your file. However, there is no downside to not answering them if you do not have something to add. 1. If you would like to share more information about your academic record, do so here. (Topics could include a special academic focus, periods of lower-than-normal grades, a pattern of withdrawals from courses, leaves of absence from school, etc.) 1,325 character max 2. Is there any autobiographical information, including formative experiences that have shaped who you are today or influences that impacted your career goals (e.g., could include where you grew up, family circumstances, obstacles, health challenges, etc.), that you wish to tell us that was not included elsewhere on this form or in your personal statement draft? 1,325 character max 3. You will be asked to respond to questions such as the following on your applications. If either one of these situations pertains to you, you must disclose the information on your applications (refer to the Self Appraisal Instructions for more information on this topic). We strongly encourage you to write out your potential answer(s) here so that we can help you craft effective answers. In your response(s), please provide: o A brief description of the incident that was the basis for the disciplinary action o The specific charge(s) made o The disciplinary action taken o A brief reflection on the insights you have gained from this experience. a. “Were you ever the recipient of any institutional action by any college or university for an academic infraction or a conduct violation, even though such action may not have interrupted your enrollment or required you to withdraw?” If you must answer Yes to this question, what do you plan to say on your application? 1,325 character max a. “Have you ever been convicted of convicted of, or pleaded guilty or no contest to, a misdemeanor crime or felony?” If you must answer Yes to this question, what do you plan to say on your application? 1,325 character max 6