University of Southern California School of Medicine
Department of Family Medicine
Primary Care Physician Assistant Program
Supplemental Application for Fall 2006 Entry
1. GENERAL INFORMATION
TYPE OR PRINT LEGIBLY
Name: ____________________________________________Other Name(s): ______________________________
Last
Gender: Male____
First
M.I.
Last
First
M.I.
Female_____
Home Telephone No.: (______)_________________________Email: _________________________________
Mailing Address: _____________________________City: _____________________State: _____Zip: _________
Date of Birth: ____/______/_____ Place of Birth: _________________________________
Current Job Title: _________________________________________________________
Current Employer: _________________________________________________(______)____________________
Name
Address
Telephone No.
Ethnicity (circle one):
African-American/Black Caucasian
Chinese Japanese Korean
Pacific-Islander Other Asian Mexican-American Native-American(tribe_______________)
Latin-American
Central American
Other ethnicity__________________
Resident Status (circle one): U.S. Citizen
International
Permanent Resident
Previous Entry Years Applied (circle all that apply): 2005-04 2004-05 2003-04
2002-03
2.
SKILLS (Place a check in the box next to the items with which you have proficiency.)
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history taking
physical examination
vital signs
first aid
cardiopulmonary resuscitation
EKG interpretation
Psychiatric counseling, e.g., “hot line”-other
counseling
Physical therapy
Respiratory therapy
Splinting and/or casting
cultural interpretation
gastric lavage
taking x-rays
injections
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venipuncture
catheterization
Suture removal
Suturing
Microsopic evaluation of:
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blood
urine
gram-stained specimens
other__________________________
Filipino
Puerto-Rican
Supplemental Application - page 2 of 2
3.
MILITARY POSITIONS
(If your job title is/was clinical in nature, please list this
information above in clinical experience.)
a) Title ______________________ Location ______________From_________ To __________
b) Title ______________________ Location ______________From_________ To__________
4.
CURRENT LICENSES
Date
Date
a) Title _________________________ State _________ Issued __________ Expires________
Date
Date
b) Title _________________________ State _________ Issued __________ Expires________
I.
PERSONAL STATEMENT
Write a one-page, personal statement which gives the Selection Committee a good
indication of who you are. For example, what experiences in your life have helped
shaped you as a person, what obstacles you have had to overcome, what people have
been most influential in your personal development and why, what motivates you, what
you feel most passionate about, etc.). Please do not reiterate work experience, honors,
achievements or other items which have already been listed in the CASPA application.
I certify that in compliance with Section 41301, Article 1.1, Title 5, California
Administrative Code, I have supplied complete and accurate information. It is understood
that failure to file complete and accurate information will be grounds for denial of
admission, cancellation of academic credit, suspension, or expulsion from the USC
Primary Care Physician Assistant Program. I understand that a criminal record can
obstruct one's ability to obtain a physician assistant license.
Applicant's Signature _____________________________________Date
_____/______/______
PLEASE RETURN THIS FORM, PERSONAL STATEMENT, $35 PROCESSING
FEE AND UNOFFICIAL TRANSCRIPTS BY OCTOBER 31, 2005 AND NO
LATER THAN DECEMBER 1, 2005 DIRECTLY TO:
USC PA Program
ATTN: Admission Office
1000 South Fremont Avenue, Unit 7
Bldg. A-6, 4th Floor
Alhambra, CA 91803