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Biosketch Template

STUDENT BIOGRAPHICAL INFORMATION FORM

(BIOSKETCH)

Name:

Phone: Beeper: E-mail: @virginia.edu

Use this form to keep records that you will need throughout medical school. You will be required to provide this form when requesting letters of recommendation for scholarships, research, and for your Medical Student Performance Evaluation for residency programs during your fourth year. The data provided will be very helpful to you when constructing your CV. We recommend that you keep this updated, including scholarships, research positions, etc. Please list dated information chronologically. Handwritten forms will be returned to your mailbox. Please see Ginny Atwell (924-5579) in the Office for Student Affairs, 1st floor McKim Hall, Rm. 1162, if you need assistance using this form template.

UNDERGRADUATE EDUCATION:

1.List all undergraduate colleges attended. Include double majors, minors, etc.

List Chronologically:

College/University / Dates / Major / Minor / Degree

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2.List all honors received during your undergraduate education. If you attended more than one college, please specify which honors were received at each college. Include Dean’s List (how many semesters), honor societies, awards, scholarships, etc.

List Chronologically:

Honor Description / College/University / Date(s)

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3.List all research activities conducted during your undergraduate education. Please make this a brief summary (1-2 sentences).

List Chronologically:

Dates, Location & Supervisor
(include credentials)
(ex: John C. Doe, M.D., Ph.D.) / Topic
(brief; 1-2 sentences) / Publications and/or Presentations
(Author/s, Journal Title, Yr, Vol., Pgs.)
ex: Journal of Neurochemistry (1998;73:217-232)

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4.List all extracurricular, leadership & community activities during your undergraduate education. If you attended more than one college, please specify which activities you were involved in at each college. Include dates. Be sure to list volunteer work, summer activities, hobbies, sports, etc.

List Chronologically:

Activity Summary / College/University / Date(s)

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5.List all employment during your undergraduate education. Include summer jobs, dates of employment, etc.

List Chronologically:

Employment / Date(s)

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6.Professional Memberships during your undergraduate education:

List Chronologically:

Professional Memberships / Date(s)

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POST-BACCALAUREATE CAREER INFORMATION: (excluding graduate school)

1.If you did not enter medical school or graduate school immediately after graduating from college, please cite reason and outline your activities (jobs held, positions, etc.) in chronological order.

List Chronologically:

Description of Activity / Date(s)

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2.List all honors received during your post-baccalaureate career.

List Chronologically:

Honor Description / Date(s)

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3.List all research activities conducted during your post-baccalaureate career. Please make this a brief summary (1-2 sentences).

List Chronologically:

Dates, Location & Supervisor
(include credentials)
(ex: John C. Doe, M.D., Ph.D.) / Topic
(brief; 1-2 sentences) / Publications and/or Presentations
(Author/s, Journal Title, Yr, Vol., Pgs.)
ex: Journal of Neurochemistry (1998;73:217-232)

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4.List all extracurricular, leadership & community activities during your post-baccalaureate career. Include dates. Be sure to list volunteer work, summer activities, hobbies, sports, etc.

List Chronologically:

Activity Summary / College/University / Date(s)

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5.Professional Memberships during your post-baccalaureate career:

List Chronologically:

Professional Memberships / Date(s)

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GRADUATE EDUCATION: (excluding medical school)

1.List all graduate schools attended

List Chronologically:

College/University / Dates / Major / Minor / Degree

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2.List all honors received during your graduate education. If you attended more than one college, please specify which honors were received at each college. Include Dean’s List (how many semesters), honor societies, awards, scholarships, etc.

List Chronologically:

Honor Description / College/University / Date(s)

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3.List all research activities conducted during your graduate education. Please make this a brief summary (1-2 sentences).

List Chronologically:

Dates, Location & Supervisor
(include credentials)
(ex: John C. Doe, M.D., Ph.D / Topic
(brief; 1-2 sentences) / Publications and/or Presentations
(Author/s, Journal Title, Yr, Vol., Pgs.)
ex: Journal of Neurochemistry (1998;73:217-232)

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4.List all extracurricular and community activities during your graduate education. If you attended more than one college, please specify which activities you were involved in at each college. Include dates. Be sure to list volunteer work, summer activities, hobbies, sports, etc.

List Chronologically:

Activity Summary / College/University / Date(s)

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5.List all employment during your graduate education. Include summer jobs, dates of employment, etc.

List Chronologically:

Employment / Date(s)

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6.Professional Memberships during your graduate education:

List Chronologically:

Professional Memberships / Date(s)

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MEDICAL EDUCATION:

1.List all medical schools attended (including UVa). Please indicate if you entered UVa School of Medicine by the MD/PhD (MSTP) Program, etc.

List Chronologically:

Medical School(s) / Dates Attended / Reason for Leaving

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2.List all honors received during your medical education. If you attended more than one college, please specify which honors were received at each college. Include Dean’s List (how many semesters), honor societies, awards, scholarships, etc.

List Chronologically:

Honor Description / College/University / Date(s)

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3.List all research activities conducted during your medical education. Please make this a brief summary (1-2 sentences).

List Chronologically:

Dates, Location & Supervisor
(include credentials) (ex: John C. Doe, M.D., Ph.D.) / Topic
(brief; 1-2 sentences) / Publications and/or Presentations
(Author/s, Journal Title, Yr, Vol., Pgs.)
ex: Journal of Neurochemistry (1998;73:217-232)

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4.List all extracurricular, leadership & community activities during your medical education. If you attended more than one college, please specify which activities you were involved in at each college. Include dates. Be sure to list volunteer work, summer activities, hobbies, sports, etc.

List Chronologically:

Activity Summary / College/University / Date(s)

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5.List all employment during your medical education. Include summer jobs, dates of employment, etc.

List Chronologically:

Employment / Date(s)

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6.Professional Memberships during your medical education:

List Chronologically:

Professional Memberships / Date(s)

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The information in this section applies to your fourth year when you will be seeking a residency position and participating in the NRMP Match. Please fill out what is applicable at this time, and update as you approach your fourth year.

PERSONAL INFORMATION:

Faculty Advisor:

Please list the names of faculty who will write letters of recommendation for residency (minimum of 3):

Name / Department

If married, spouse’s name:Occupation:

Are you a member of the Armed Forces or the PHS Scholarship Program?Yes No

If yes, what service? Air Force Navy Army Other:

What type of residency (specialty) do you wish to pursue? (Prior to 4th year, what is your best guess as to what area of medicine you would like to practice?)

Type of Residency / Geographic Area / Type of Practice / Type of Community

How would you describe yourself? (Include 5 adjectives that best describe you)

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What are your interests outside of medical school? (i.e. hobbies, avocations, etc.)

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Is there some personal information regarding your background/achievements that you would like us to know? (indicate if you want it to be included in your letter of recommendation)

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