MissouriState UniversityPremedicalCommittee

Application to thePremedical Committee

Instructions

1. Submit a copyofyour MCATscores to Dr.Amanda Brodeur, Chair ofthe Premedical Committee (Professional 352; ). Based onyour MCAT scores andyour MSU academicrecord, Dr.Brodeurwilldetermineyour eligibilityforaPremedical Committee interview. Thecommitteewillnot interviewstudents whose academicrecord is likelyto precludeadmission to medical school.

2. Submit this application to Dr.Brodeur(Professional 352; ). Theapplication packet consistsof thefollowingitems:

Completed Request forPremedical CommitteeInterview(attached). Besureto attacha current photograph ofyourself.

Completed and signedStudent Personal History/Profile(attached). Createaneat, accurate and typed form. Your personal statement presents an opportunityto distinguishyourself from other applicants and should betaken seriously.

Completed and signedWaiverform for the committee evaluation(attached).

Two completed and signedRequests for Evaluation/Recommendation(attached). Leave

the “name ofevaluator”blank on theseforms.

At least one completedand signedDoctorShadowing VerificationForm(attached).

Copies of allMCAT scores (may be submitted later for July interviews).

Unofficial copies of allcollege academictranscripts.

3. Make an appointment tomeet with Dr.Brodeur.Prior to this meetingsend anelectronic copyofyour application,your transcript,your shadowing verification forms andyour MCAT scores.At themeetingDr. Brodeurwillhelp selectyour two MSU facultyevaluatorsfor one-on-oneinterviews. Typically, one evaluator willbe somebody you know who isapre-medical advisorand the other evaluator will be afacultymember who is familiar with premedicalstudies and who mayormaynot knowyou. Members of the Premedical Committeecan, and frequentlydo, serve as evaluators. You willkeep the two Request forEvaluation/Recommendationforms to give toyour evaluators.

4. Dr. Brodeur willconfirmwithyou the selected evaluatorsand thenyou should contact each person and makea45-minuteappointmentfora one-on-oneinterview. Oncethe individual interviews havebeenconfirmed contact Dr.Brodeur and shewillmakesureeach interviewerhas copies ofthe followingitemsfromyour premedical committee applicationpacket:

Student Personal History/Profile

DoctorShadowing VerificationForm(s)

MCAT scores

Academic transcripts(unofficial)

At the timeof theinterviewyou must provideyour evaluatorwith the completed and signed Request forevaluation/Recommendation. Thewaiveron this form mustbe completed and signed by you beforetheinterview commences.

5. As soon asyour application is complete (allmaterials listed under item #2 plus thetwo personal evaluations), acommittee interview willbescheduled. Committeeinterviews are conducted by asubset ofthe Premedical Committee(usually4 members) and typicallylast 45-60minutes. After the interviewis over, theCommitteemembers who werepresent at the interview willdiscuss yourcredentials andwillselect a level of recommendation from thefollowinglist:

Recommended enthusiastically

Recommended highly

Recommended

Recommended with reservations

Not recommended

Ifupon learningof theoutcomeyouwish to proceed withyour application, two members ofthe Premedical committeewilldraft adetailed letter ofrecommendation that high-lightsyour strengths within the context of ouroveralllevel ofrecommendation.

MissouriState UniversityPremedicalCommittee

Request forPremedical CommitteeInterview

Instructions: Complete onlythe top portion ofthis pageand insert a current photographwhere indicated. Emailthis form and allother components of the Premedical CommitteeApplication packet to theChairperson ofthe Premedical Committee(Dr. Brodeur, Professional 352).

Name

LastFirstInitial

Local Address

StreetCityZip

Local PhoneNo.

MSUID(M-number)

Advisor

AcademicDepartment

E-mail Address:

ForPremedical CommitteeUse

Student Personal History/Profilereceived

Transcript(s) received

MCATscores received

Written Evaluation/Recommendation received

Names ofEvaluators:,

Student is eligiblefor committee evaluation/recommendation

Student notified of interview status

Interview scheduled: Date

Time Place

Attach Photo Here

MissouriState UniversityPremedicalCommittee

Student Personal History/Profile

Instructions: Please open this form in MS Word and typetherequested information. Do not simply print this form and provide theinformation as attachments.

A.Personal Data

Last NameFirstMI

MSUID(M-number) Date ofBirth

PlaceofBirth

CityStateZip

Local Address

StreetCityZip

Local Phone:

E-mail:

B.Pre-CollegiateExperience

Providethe name(s) of thehigh school(s)you attended, the cityand the statein which they werelocated, and theyears attended.

High School name / City / State / Years

C.CollegiateActivities

a. Listallcolleges and universities (otherthanMissouri StateUniversity)thatyouattended, location and dates attended.

CollegeorUniversityname / City / State / Years

b. Howmanysemesters haveyou attendedMissouri StateUniversityincludingthe present semester?

c. In the spacebelow, list anyprofessional, honorand/or social organizations to whichyou belong.

d. Listand describeanyactivities, curricular orextra-curricular,and/or honors whichyou havereceived thatyoufeel have contributed toyour personal development. Pleaseinclude years ofparticipation.

D.WorkExperience

Listprior/current employment thatyou thinkis relevant to your medical school application. Provideajob description, numberof hours worked each week,and the dateof employment.

Placeof Employment / Description / Hours/week / Dates

E.VolunteerExperience

Listprior/current volunteer work thatyou thinkis relevant to your medical school application. Provideajobdescription;numberofhours workedeachweek,and the date of employment.

Placeof Volunteer Work / Description / Hours/week / Dates

F.Shadowing Experience

Listallshadowingexperiences.

Physician Shadowed / Doctor’s specialty/ hospitalaffiliation/city / Dates / # of hours

G.Reading

Listbooks/papers/journals read in thepast 2-3years that arerelated toyourinterest in

medicine.

H. Shadowing ExperienceStatement.

Writeashort essay(350-500 words) onyour shadowingexperiences. Thisshould bea

personal account. Youraccountshould describewhatyou learnedfrom this experience andcould includesomeof thefollowing:descriptions ofyour activities; descriptions of thephysician’sdaily activities; descriptions of memorable incidents;descriptions of theroles andresponsibilitiesof all the members of thehealth careteamyou observed;observations related to thephysician-patient

interactions; observations related to thephysician-nurseor physician-staffinteractions; and howyou feltabout the experience.

I.Personal Statement

This statement should reflect onyour interest in medicine as acareer. Bebiographical and provide relevant information aboutyour achievements.Include astatementaboutyour future aspirations and whatyou hopeto be doingintenyears. This statement should be at least onepagein length butno longer than two pages. This maybethe same as or similarto thestatement thatyou useonyour AMCASor AACOMAS application.

Iverifythat the information on this form is trueto thebest of myknowledge.

SignatureDate

Waiver

Inaccordancewith the FamilyEducational Rightsand PrivacyAct,Iunderstand thatImay voluntarilywaivemyright to inspect or viewthe letter of evaluation/recommendation prepared bythe Premedical CommitteeofMissouri StateUniversitythat willbesubmitted to themedical schools of mychoice. Ifurther understand that ifI waive myright to inspect or viewthis letter such action is irrevocable, andIwillnot be permitted to view orotherwiseobtain any information contained inthis letter. Irecognizethat a waiver is not a requirement for consideration ofmyapplication or anyotherservices fromMissouri StateUniversity.

Iwaive myright to inspect or viewthis letter.

Ideclineto waivemyright to inspect or viewthis letter.

Name(Pleaseprint)MSU ID(M-number)

SignatureDate

Student's LastNameFirstMIMSU ID(M-number)

MajorAdvisor

Waiver

(Pleasechecktheappropriateboxandsign)

I recognizethatthisevaluation/recommendation issoughtforthepurposeof presentingtomedicalschoolsanaccurateevaluation/recommendation.Inaccordance withtheprovisionsoftheFamilyEducationalRightandPrivacyAct,Iwaive

donotwaivemyrightofaccesstothisevaluation/recommendation.I recognize thatawaiverisnota requirementforconsiderationof myapplicationoranyother servicesfromMissouriStateUniversity.

SignatureofstudentDate

Dear

:

Nameof evaluator

Thestudent whosenameappearsaboveintends toapplyfor admission to amedical school and has chosenyou to provide anevaluation/recommendation. Each student requestingthis evaluation/recommendation has been instructed toask for anevaluation/recommendation from an individual who is willingto interviewthe studentand makesignificantcomments to the Premedical Committee. Thestudent has been requested to setup a30 to 45 minuteinterview withyou to assist you in writingthis evaluation/recommendation. Our goal is to supplement thestudent’s academic recordand to assist theadmissions officers ofmedical schools in makingdifficult choices. Your candid evaluation/recommendation regardingthisstudent will be greatlyappreciated.

Provided that the student has waived access toyour evaluation/recommendation, this evaluation/recommendation willbeheld in strict confidenceand used onlyin thestudent’s application for admissionto medical school.

You will be provided with aformcontainingsomestandard questions and to whichyour written evaluation should be attached. Pleasereturn this formto Dr. Amanda Brodeur,Biomedical Sciences Department, oras an emailattachment (). Thankyouforyour time.

Student's LastNameFirstMIMSU ID(M-number)

MajorAdvisor

Waiver

(Pleasechecktheappropriateboxandsign)

I recognizethatthisevaluation/recommendation issoughtforthepurposeof presentingtomedicalschoolsanaccurateevaluation/recommendation.Inaccordance withtheprovisionsoftheFamilyEducationalRightandPrivacyAct, Iwaive

donotwaivemyrightofaccesstothisevaluation/recommendation.I recognize thatawaiverisnota requirementforconsiderationof myapplicationoranyother servicesfromMissouriStateUniversity.

SignatureofstudentDate

Dear

:

Nameof evaluator

Thestudent whosenameappearsaboveintends toapplyfor admission to amedical school and has chosenyou to provide anevaluation/recommendation. Each student requestingthis evaluation/recommendation has been instructed toask for anevaluation/recommendation from an individual who is willingto interviewthe studentand makesignificantcomments to the Premedical Committee. Thestudent has been requested to setup a30 to 45 minuteinterview withyou to assist you in writingthis evaluation/recommendation. Our goal is to supplement thestudent’s academic recordand to assist theadmissions officers ofmedical schools in makingdifficult choices. Your candid evaluation/recommendation regardingthisstudent will be greatlyappreciated.

Provided that the student has waived access toyour evaluation/recommendation, this evaluation/recommendation willbeheld in strict confidenceand used onlyin thestudent’s application for admissionto medical school.

You will be provided with aform containingsomestandard questions and to whichyour written evaluation should be attached. Pleasereturn this formto Dr. Amanda Brodeur,Biomedical Sciences Department, oras an emailattachment (). Thankyouforyour time.

DoctorShadowingVerification Form

MissouriState University

Pre-MedicalCommittee

Student’s Name:

Name of Dr. Shadowed:

Doctor of:

Name ofHospital, Office, etc.

Date/s: Duration (total in hours):

Activityof Shadow(Office, OR, etc.) and brief description of what studentdid/learned:

Please comment on thestudent’s performanceregardingpunctuality, professionalism, motivation

and suitabilityformedical school and acareerasaphysician:

Student Signature:

Doctor Signature:

Date: