INSTRUCTIONS : TO ENTER DATA, CLICK THE GRAY BOX AND BEGIN TYPING (THE GRAY BOX WILL DISAPPEAR). DO NOT WORRY IF
THE BOXES MOVE AROUND AS YOU ARE ENTERING DATA. SAVE THIS COMPLETED FILE TO YOUR COMPUTER’S HARD DRIVE AND
UPLOAD IT INTO YOUR DISCOVER ACCOUNT AS THE FILE “ ADDITIONAL DEMOGRAPHICS AND FUTURE PLANS ” FORM.
1.
Full Legal Name:
2.
Personal Email Address:
(DO NOT INCLUDE INSTITUTIONAL
OR ORGANIZATIONAL ADDRESS.
ENTER ONLY YAHOO, HOTMAIL,
GMAIL, ETC.)
3.
Have you had ANY previous
MD Anderson experience?
IF YES, INDICATE THE POSITION HELD &
DEPARTMENT.
4.
Residential Status:
MUST CHECK ONE.
Yes No If YES, Explain
The information provided herein is used to encourage underrepresented minorities, socioeconomically disadvantaged and first generation college students to apply to MD
Anderson programs. The demographics data is reported only to the National Cancer Institute.
5.
Primary Language 6.
Preferred Language
7.
Race and Ethnicity
CHECK ALL THAT APPLY.
American Indian
Alaska Native
Asian
Native Hawaiian/Pacific Islander
Black/ African American/African Descent
White/Anglo/European Descent
8.
Regardless of how you answered the previous question...
Are you Hispanic or
Latino?
CHECK ONE BOX.
9.
Mother’s Highest Degree CHECK ONE BOX.
Yes No
10.
Father’s Highest Degree CHECK ONE BOX.
Grade School (K-6)
Middle School (7-8)
High School
GED
Some College
Associates Degree
Trade/Technical Program/Degree
Undergraduate Degree (Bachelor’s or Technical)
Graduate Degree
Some Graduate School
Advanced Degree (MD, PhD, Other)
Military
Not Applicable
Unknown
Grade School (K-6)
Middle School (7-8)
High School
GED
Some College
Associates Degree
Trade/Technical Program/Degree
Undergraduate Degree (Bachelor’s or Technical)
Graduate Degree
Some Graduate School
Advanced Degree (MD, PhD, Other)
Military
Not Applicable
Unknown
11.
Are you from a
Disadvantaged
Background?
CHECK ONE BOX.
Yes No
An individual from a disadvantaged background is defined as one who comes from an environment that has inhibited the individual from obtaining the knowledge, skill, and abilities required to enroll in and graduate from a health professions school, or from a program providing education or training in an allied health profession; or comes from a family with an annual income below a level based on low income thresholds according to family size published by the U.S. Bureau of Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary, HHS, for use in health professions and nursing programs.
12.
Are you the first individual in your family to attend college?
CHECK ONE BOX.
Yes No N/A– not yet in college
13.
Are you the first individual in your family to graduate
from college?
CHECK ONE BOX.
Yes No N/A– not yet in college
Staying with Friend/Relative Renting an Apartment Hotel/Motel Commuting Undecided
14.
Housing Plans
CHECK ONE BOX.
Other: Explain

15.
Transportation
Plans
CHECK ONE BOX.
I have my own Car I plan to buy a car Carpooling/Shared Ride Public Transportation Undecided
Other: Explain
16.
Enter your most recent cumulative GPA?
You must submit transcripts for all institutions you attended (post high school/GED) by the application deadline.
17.
What are your long-term educational goals?
CHECK ALL THAT APPLY.
18.
Indicate the semesters in which you are enrolled in a degreegranting program.
CHECK ALL THAT APPLY.
PhD MD MD/PhD MS MPH DrPH Other, indicate here:
Current Spring Semester Upcoming Fall Semester
19.
If you did not check the Upcoming Fall
Semester box above, have you applied for admission to a degree program following the one in which you are currently enrolled?
20.
What is your current
SPRING SEMESTER academic designation (of this application year) ?
MUST CHECK ONE BOX.
Yes No* If No, Explain
Undergraduate Sophomore
Undergraduate Junior
Other. Please indicate here:
Undergraduate Senior
Graduate Student
Medical School
Student
Doctoral Student
Nursing Student
Not Enrolled in School for current
Spring semester.
(*) TO BE ELIGIBLE FOR THIS FELLOWSHIP, PROOF OF ENROLLMENT OR PROOF OF ACCEPTANCE INTO A GRADUATE PROGRAM OR
MEDICAL SCHOOL WILL BE REQUIRED.
21.
What will be your
FALL SEMESTER academic designation (of this application year) ?
MUST CHECK ONE BOX.
Undergraduate Junior
Undergraduate Senior
Graduate Student
Medical School Student
Doctoral Student
Nursing Student
Not Enrolled in School for Fall semester.
Other, please indicate here:
22.
Briefly describe your educational goals in the space below. (Limit: Not to exceed 2 paragraphs)
Please include the areas of study in which you are interested.
23.
If you have applied to a subsequent degree program, please list the institutions to which you have applied. If you have not, please outline your career path.
(Limit: Not to exceed 1 paragraph.)

24.
If you have accepted an offer from an institution, please provide the institution's name.
If you have not accepted an offer, please outline your expected date for notice of acceptance and your preferred institution(s).
25.
Please provide any additional details you feel are important regarding your future academic plans and your sought after role at
MD Anderson. (Limit: Not to exceed 2 paragraphs)
Providing test scores will assist in the selection process.
26.
ACT - include date taken, English, Math, Reading, Science, Composite and Writing Scores
27.
SAT - include date taken, Critical Reading, Math, Writing and Subject Tests if Applicable
28.
GRE - General Test - include date taken, Analytical Writing, Verbal Reasoning, Quantitative Reasoning
29.
MCAT - include date taken, Verbal Reasoning, Physical Sciences, Writing Sample and Biological Sciences
30.
If you have none of the above referenced test scores to provide, please indicate the reason why test scores are not provided.