The University Of Toledo
Physician Assistant Program
Primary Care Specialty Track Form
Applicant Name:
Permanent Mailing Address:
Email Address:
Phone Number:
Economically Disadvantaged: Please type ‘yes’ or ‘no’:
To determine if you come from an economically disadvantaged background, you are
asked to use your parent's 2010 income (unless you are over the age of 30, in which
case use your own 2010 income). Please reference the table below to determine if your
parental family income (or your own, if over the age of 30) based on size of household
(number of exemptions listed on Federal income tax forms) qualifies for federal lowincome level based on 200 percent of poverty guidelines. Consideration will be given to
applicants from an economically disadvantaged background, but this is not necessary.
S i ze o f Fa m i l y*
Inc ome Le ve l **
1
$21,780
2
$29,420
3
$37,060
4
$44,700
5
$52,340
6
$59,980
7
$67,620
8
$75,260
For each additional
person add:
$7,640
* means number of exemptions listed on Federal income tax forms
(e.g. family size of 4 might include two parents and two dependents).
** Adjusted gross income for calendar year 2011.
The University Of Toledo
Physician Assistant Program
Primary Care Health Professional Shortage Area: Please type ‘yes’ or ‘no’:
Medically Underserved Area/Population: Please type ‘yes’ or ‘no’:
Note: To determine if you are from a Primary Care Health Professional Shortage Area
and/or Medically Underserved Area/Population, please visit the following website and
enter your permanent address:
http://datawarehouse.hrsa.gov/GeoAdvisor/shortagedesignationadvisor.aspx
Primary Care Experience:
Please list all primary care (family practice, general internal medicine and general
pediatrics) healthcare experiences. Consideration will be given to applicants with
significant primary care experience, but this is not necessary. Include your role or job
title (ex. Shadow, medical assistant, etc.), a brief explanation of your duties in that
role/job title, and the approximate total number of hours in that role/job title as of July 1,
2011. If you have had more than three different experiences, please add this
information at the end of this form.
Role / Job Title:
Explanation of Duties:
Number of Hours:
Role / Job Title:
Explanation of Duties:
Number of Hours:
Role / Job Title:
Explanation of Duties:
Number of Hours: