Department of Physician Assistant Education

2016 Supplemental Application (for the class starting June 2016)

Department of Physician Assistant Education

Stony Brook University

Instructions:

1.  Complete the supplemental application and email it to . Use your last name and first name as the file name. (e.g. Smith.John)

2.  Please Provide the Following Required Information:

Name: ______

Street: ______

City: ______State: ______Zip: ______

Email: ______

Home Phone: ______Cell phone: ______

ü  Are you a New York State (NYS) Resident? YES______NO______

o  If Yes, Length of NYS Residency: YEARS______MONTHS______

ü  Are any of your relatives alumni of the Stony Brook PA Program? ____YES _____NO

ü  Have you previously applied to the Stony Brook PA program? ____YES ____NO (if yes, what year(s) ______)?

ü  Have you previously been interviewed at the Stony Brook PA program? ____YES ____NO

o  (If yes, what year(s) ______)?

CASPA applications are not considered complete and will not be reviewed until the

required supplemental application and on-line fee are received by the program.

Please answer each of the following questions 250 words or less:

1.  What three attributes of the Stony Brook PA program most influenced you to apply to our program and why?

2.  Other than becoming a competent medical provider, discuss two other skills that you hope to learn as a student in the Stony Brook PA program?

3.  Do you consider yourself to be a role model? If so, to whom and why?

4.  Based on your clinical experience, identify a health care challenge you have encountered. Describe specific steps you initiated to overcome this obstacle and the impact this had on patient care outcomes.

5.  Describe your experience caring for medically underserved populations and its impact on your goals as a future health care provider.

6.  List any leadership positions or roles you have assumed and discuss how these experienceshave influenced your leadership style.

Please carefully read and consider the following. Then sign electronically in the place indicated.

Ø  Any falsification of information provided by an applicant related to his/her CASPA or supplemental applications will result in the nullification of an interview offer and/or offer of admission.

Ø  Felony and Misdemeanor Conviction Disclosure Statement

Many of the clinical affiliates that are utilized by the program require background checks of any student who will be interacting with patients or who rotate through their facility. Therefore, all students admitted to the Stony Brook Physician Assistant Program are required to complete a criminal background check and provide the program with the final report by no later than June 20, 2016. Instructions will be provided to those candidates offered seats after they have indicated that they accept an offer of admission to our program. Failure to provide a copy of the criminal background check by the June 1, 2015 deadline will result in automatic rescission of any offer of admission.

I have read the statements above and agree to the terms specified. I explicitly acknowledge that I must obtain a criminal background check if I am offered a seat in the program and understand that if admitted I am required to provide the program with a copy of the results of said criminal background check from the agency specified by the Stony Brook PA Program by no later than June 20, 2016.

Last name First name

Electronic Signature Date

This page must be returned with your supplemental application.

Department of Physician Assistant Education

Stony Brook University

2015-2016 Admission Cycle