Johnny Sample
DOWNLOAD this electronic form at
http://www.utdallas.edu/pre-health/forms/
TYPE your answers. PRINT the form.
Johnny Sample
UTD ID: 12345…10
UTD ID: 2012345678
BIOGRAPHICAL FORM 2016 SAMPLE
7/12/2016
This date auto-updates.
This MUST be the name which
appears on your official transcripts.
To complete a Biographical Form, DOWNLOAD a
blank one from www.utdallas.edu/pre-health/forms,
then TYPE your answers and PRINT the form.
I. BACKGROUND INFORMATION
Professional program to which you are applying: Medical
Are you applying to enter professional school in fall 2017? Yes
Have you previously applied to medical or dental school? Yes
If yes, when? 2015
U.S. citizen or permanent resident? Yes
If no, country of citizenship: ______
Texas resident? Yes
If no, state of residency:
______
Ethnicity:Hispanic
Native language: English
Other fluent languages: Spanish
Do you plan to complete a degree at UT Dallas? Yes
If yes, what is your major? Dance, minor Nanobiology
When do you expect to graduate? May 2016
List the name, year, and institution of any degrees you have
already completed.
attach 4x6 photo here
A business-like photo with your face
clearly visible is most appropriate for
HPE and for professional schools.
I needcannot
to hire produce
a photographer?
MostDo
printers
good quality
No: a photograph just helps to put a face
photos. Use a “photo printer” and “photo paper,”
with your name. A great photo doesn’t
or have a print
$0.25
at most drug stores.
makemade
you afor
better
applicant.
Answer “yes” only if
you intend to complete
a UTD degree or
certificate.
That said, a poor or overly-casual photo
can create the wrong impression.
No beach parties, martini glasses, or cats.
Can I print a photo from my home printer?
Not unless you own a “photo printer” and
print to “photo paper.”
II. YOUR EVALUATORS
HPE participants must solicit 3 letters of evaluation (max 5), including two from science professors.
Evaluator Name
Position
Relation to You
HPE requires 3 letters of evaluation, including 2 from science professors:
biology, chemistry, or physics. Math, geology, neuroscience, or
engineering may be acceptable—ask your HPE advisor.
Avoid family members or
friends as letter writers.
Healthcare providers, volunteer and research supervisors, and employers
are also commonly-asked letter writers.
Choose writers who know you well and can attest to multiple aspects of
your healthcare-suited personality.
Health Professions Evaluation Biographic Data
(7/12/2016) – Page 1 of 6
UTD ID: 12345…10
Johnny Sample
III. ACADEMIC SUMMARY.
 Use the GPA Calculator at www.utdallas.edu/pre-health/forms
 Include years attended (i.e. “2000-2004”) in your entry below
 Include graduate work—it won’t otherwise be seen by professional schools.
Credits
Overall
GPA
Richland Community College, 2009-2010
24
4.00
University of Texas at Dallas, 2010-2013
87
3.63
Institution
BCPM
Science
Credits
BCPM
Science
GPA
Where Can I Get
My GPA?
60
3.45
Use the
GPA Calculator
at
www.utdallas.edu/prehealth
/forms
Total/Averages:
111
3.69
60
3.45
IV. STANDARDIZED TEST SCORES
Include all past tests and planned future tests.
Dental Admission Test (DAT)
Medical College Admission Test (MCAT)
Date
Bio. Sci.
Phys. Sci.
Verbal
Reasoning
Total
Score
Writing
Sample
6/8/11
12
11
8
31
S
Date
PAT
QRT
RCT
BIO
Gen.
Che
Org.
Che
Total
Sci
AC
Avg
7/1/13
A date with no scores indicates a
scheduled test date
TMDSAS NOTE: In most sections, you’re allowed an unlimited number of entries with a 300character description of each.
AMCAS NOTE: The AMCAS application allows only 15 entries across all categories.
V. ACADEMIC RECOGNITION
Describe any academic honors, awards, and other recognitions received since beginning college to the present.
Date
Activity/Honor
Description of Activity/Honor
Awarded
Student Gov President
Elected for 2013-2014, based on service to campus and
5/2013
campaigning
Academic Excellence
$1000/sem award for 8 sems, based on high school GPA & SAT
8/2010
Scholarship
Outstanding Student
Annual award for excellent research proposal, based on lab work
6/2010
Researcher
and presentation to faculty.
Include any awards, grants, elected or appointed positions, or memberships in selective academic groups.
Health Professions Evaluation Biographic Data
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UTD ID: 12345…10
Johnny Sample
VI. LEADERSHIP EXPERIENCE
Describe any leadership roles or positions of responsibility held since beginning college to the present.
Role Title
Student Gov President
Research Lab Leader
Description of Responsibilities
(including “hours/week” and “hours total”)
Represented students to UTD administration. Led establishment
of new policies, tech, and campus activities. Oversaw 50-student
council, 12 student orgs, 7 staff. 12 hrs/wk, ~300 hrs.
Green Fellowship – coordinated 4 undergrad researchers. 40
hrs/wk, 640 hrs
Dates
From To
5/13 / 12/13
1/12 / 5/12
Describe activities thoroughly. Use abbreviations wherever you
can do so without creating confusion. DEFINITELY describe
your responsibilities, including hours/week and duration.
VII. RESEARCH EXPERIENCE
Describe any significant research activities you have participated in since beginning college.
Role Title
(include your responsibilities, “hours/week” and “hours total”)
Green Fellowship – Planned and executed investigation of
methamphetime use on neural plasticity in mice. Designed
experiments, coordinated research team. Measured 20 subjects
(divided into 5 dosage levels) at learning tasks over 6 weeks, then
dissected brains to asses plasticity using micropulse EEG. Findings
presented to faculty and published locally. 40 hrs/wk, 640 hrs.
Supervisor
Dr. Inno Vater
Dates
From To
1/12 / 5/12
Describe the project in a brief, easy-to-understand way. Indicate the type of project, your role,
and any special equipment or skills you used. If results were presented or published, say so.
If your job was cleaning pipettes, it’s okay to say so.
VIII. HEALTHCARE RELATED EXPERIENCES
Describe experiences where you worked with or observed patients or health professionals since you began college.
Activity
Shadowed Patch Emmup, MD
Green Fellowship
Description
(including “hours/week” and “hours total”)
RHD Hospital burn ward; observed treatment methods &
patient care. Discussed pathologies and treatments with the
burn team. 15 hrs/wk, 60 hrs.
40 hrs/wk, 640 hrs. See Leadership, Research
Describe your responsibilities, what you learned, and key skills
you practiced. If an activity put you in contact with doctors or
patients, make sure that your description makes that clear.
Dates
From To
2/10 /
1/12 / 5/12
Save space by referencing
another section, if the two
descriptions would be the same.
Health Professions Evaluation Biographic Data
(7/12/2016) – Page 3 of 6
UTD ID: 12345…10
Johnny Sample
IX. COMMUNITY SERVICE
Describe any non-healthcare related community service or volunteer experience that you participated in since you
began college.
Activity
Projects though AED
Peace Corps
Description
(including “hours/week” and “hours total”)
Assorted community service, esp. food drives. 15 hrs/sem, 30 hrs
Dates
From To
8/12 / 5/13
Distributed food & medical supplies in rural Paraguay. Repaired
supply trails. Groomed the burros. Full time, 10 wks, ~500 hrs
5/06 / 7/06
If you did lots of one-time events,
sum them up in one entry.
X. EXTRACURRICULAR/LEISURE ACTIVITIES
Describe any extracurricular or leisure time activities to which you devoted significant time since you began college.
Activity
Wood carving
Description
(including “hours/week” and “hours total”)
Hand carving small figures, mostly as a creative outlet. Avg
2 hrs/wk, max 10. ~500 hrs
Dates
From To
1/05 / 4/11
This is a great place to describe activities which reveal your
character, interests, or cultural diversity.
Any activity which you spent significant time on since beginning
college MAY appear in this section.
Activities suggesting your unique interests are worth mentioning.
XI. EMPLOYMENT EXPERIENCES
Describe any paid jobs that you held since you began college.
Job Title
Where Employed and Responsibilities
(including “hours/week” and “hours total”)
Dates
From
To
All paid work should appear here.
Descriptions should suggest your responsibilities
and any healthcare-applicable skills you learned
or practiced.
XII. ACADEMIC DISHONESTY AND/OR CRIMINAL ACTIVITY
Describe any actions taken against you for academic dishonesty, conduct violations, or criminal activity (including felony and/or
misdemeanor, other than minor traffic violations). Be as brief as possible while including relevant details and applicable dates.
SCHOOLS PERFORM THOROUGH BACKGROUND CHECKS!
Use Section X to briefly explain the circumstances of your record. Your description should take appropriate
responsibility and explain how you paid for your transgression and what you changed or learned from the experience.
Failure to declare academic dishonesty or criminal record usually results in automatic rejection.
On this form, list EVERYTHING—even accused, expunged, andHealth
sealedProfessions
offenses. Evaluation Biographic Data
(7/12/2016) – Page 4 of 6
On medical or dental applications, read the directions carefully to determine what you should list.
Johnny Sample
UTD ID: 12345…10
XIII. ESSAYS
The following three prompts mimic the TMDSAS essays. Compose your essay(s) using these prompt(s). Print essay(s) as a separate
document, then clip it to your Biographical Form for revision or final submission. The essay prompts are...
PERSONAL STATEMENT - required
Medical: Explain your motivation to seek a career in medicine. Be sure to include the value of your experiences
that prepare you to be a physician. Limit your response to 5000 characters.
Dental or Veterinary: Explain your motivation to seek a career in medicine/dentistry. Discuss your philosophy of
the profession and indicate your goals relevant to the profession. Limit your response to 5000 characters.
UNIQUE LIFE EXPERIENCES – optional but recommended
Briefly discuss any unique circumstances or life experiences that are relevant to your professional school
application which has not been previously presented. Limit your response to 2500 characters.
PERSONAL CHARACTERISTICS FOR DIVERSITY - optional but recommended
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
characters.
Please follow these directions carefully. Your advisor
will be impressed, and you’ll get more out of your
revision appointment.
INSTRUCTIONS for REVISING YOUR BIOGRAPHICAL FORM and ESSAYS
To participate in committee review, you MUST revise the Biographical Form and Essays with your assigned advisor at
least once. Students not participating in committee review are also encouraged to revise with their assigned advisor.
1. Look back at the Biographical Form Sample. Did you follow all the directions?
2. LABEL each essay with your name, the essay type (“personal statement,” “optional essay 1,”
etc.), the date, and the character count (with spaces).
3. SELF EDIT first.
4. PRINT your documents, one-sided only.
5. NEVER bring incomplete documents to a revision appointment.
INSTRUCTIONS for SUBMITTING YOUR BIOGRAPHICAL FORM and ESSAYS
Hand in your completed packet at HPAC (FO 2.210) before the HPE Document Deadline.
1. Label each essay with your name, the essay type (“personal statement,” “optional essay 1,”
etc.), and the date of your last revision.
2. PRINT your Biographical Form, including the chronology, one-sided only.
3. CLIP all the pages together: photo, Biographical Form, Chronology, and essays. Please do not
staple. A folder, binder, or envelope is neither necessary nor useful.
Health Professions Evaluation Biographic Data
(7/12/2016) – Page 5 of 6
Use your college transcripts to complete this section.
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 UT Dallas.
DO NOT list an activity in more than one column, even if you listed it in more than one
DO include the letter grade for each class you took.
section above. Instead, choose whichever column below is most appropriate.
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
F’10
school
UTD
S’11
UTD/
CCCC
U’11
SMU
F’11
UTD/
CCCC
S’12
U’12
F’12
UTD
S’13
UTD
UTD/
CCCC
Classes
C- Chem I & lab A
A Macroecon.
A+ Col. Algebra
A RHET 1101
A RHET 1302
A Intro. Mgmt. Acct.
B+ Chem II & lab AA+ Precalculus
A Dance Apprec. (CCCC)
A Bio I & wksp (SMU)
(D O.Chem I) & lab A
(SMU)
A Calc I (SMU)
A Intro. Fin. Acct.
A Bio II & wksp
retake: B O.Chem I
A O.Chem II & lab A
A Calc II (CCCC)
See Research
A Biochem I & wksp
A+ Phys for Bios. II & lab
A World relig. (CCCC)
A Fin. Info. Mgmt.
A Organizaton Behavior
A Bio lab
A Biochem II & wksp
Cred
hrs
14
GPA
3.57
13
3.77
9
4.00
18
4.00
15
4.00
11
4.00
Projects through AED, 15 hrs
12
4.00
Projects through AED, 15 hrs
Student Government President, 300 hrs
Healthcare or Research
Shadowed Patch Emmup, pediatrician. 60 hrs
Other Extracurricular
Employment
Wood carving, occasional
Wood carving, occasional
Your CHRONOLOGY helps
evaluators to get a sense of
your progress over time, and
to view your grades in the
context of your
extracurricular loads.
Including your hours of
involvement is CRITICAL.
See Research
Green Fellowship, 640 hrs
Health Professions Biographical Form
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