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
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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)
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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.)
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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
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