Form 3 Matriculation Survey

Background

1. What is your gender?
j Female
k
l
m
n
j Male
k
l
m
n

2. What is your age (please enter an integer)?

3. Please indicate your current marital status?
j Never Married
k
l
m
n
j Separated
k
l
m
n
j Divorced
k
l
m
n

j Widowed
k
l
m
n
j Engaged
k
l
m
n

j Married/Domestic Partner
k
l
m
n

4. What is your ethnicity?
j Hispanic or Latino
k
l
m
n

j Not Hispanic or Latino
k
l
m
n

5. What is your race? Please choose one or more.
c American Indian or Alaska Native
d
e
f
g
c Asian
d
e
f
g

c Black or African­American
d
e
f
g

c Native Hawaiian or other Pacific Islander
d
e
f
g
c White
d
e
f
g

Other (please specify) 

6. Please enter the following information for the high school you graduated from:
Name
City
County
State
Zip Code
Country
Year of Graduation

Rural/Disadvantaged Background

7. Would you consider yourself from an "environmentally disadvantaged background?"
Please answer to the best of your ability.
This may mean:
­ you are from a high school with low average SAT/ACT scores
­ you are from a school district where 50% or less of graduates on to college
­ you have a diagnosed physical/mental impairment substantially limiting participation in
education
­ English is not your primary language and has been a barrier to academic performance
­ you are the first generation in your family to attend college
­ you are from a high school where > 30% of students were eligible for free or reduced
lunch prices

j Yes
k
l
m
n
j No
k
l
m
n

8. If you answered yes, which of the characteristics apply to you? Choose all that apply.
c You are from a high school with low average SAT/ACT scores
d
e
f
g

c You are from a school district where 50% or less of graduates on to college
d
e
f
g

c You have a diagnosed physical/mental impairment substantially limiting participation in education
d
e
f
g
c English is not your primary language and has been a barrier to academic performance
d
e
f
g
c You are the first generation in your family to attend college
d
e
f
g

c You are from a high school where > 30% of students were eligible for free or reduced lunch prices
d
e
f
g

9. Would you consider yourself from an "economically disadvantaged background?"
Please answer to the best of your ability.
This may mean you come from a family:
­ with an annual income < 200% of the Federal Poverty Level (Currently $31,020 for a family
of 2; $39,060 for a family of 3; $47,100 for a family of 4; $55,140 for a family of 5)
­ that received public assistance (e.g. Aid to Families with Dependent Children, food
stamps, Medicaid, public housing)

j Yes
k
l
m
n
j No
k
l
m
n

10. Do you consider yourself from a rural background?

j Yes
k
l
m
n
j No
k
l
m
n

11. Please indicate your veteran status.
j Active Duty Military
k
l
m
n

j Reservist
k
l
m
n

j Veteran­­Prior Service
k
l
m
n
j Veteran­­Retired
k
l
m
n
j Not a Veteran
k
l
m
n

Medical School

12. Please enter the following information for your Medical School:
Name
City
State
Country

13. Does your Medical School have more than one campus?

j Yes
k
l
m
n
j No
k
l
m
n

14. If your Medical School had more than one campus, please indicate which campus you
primarily attended? (Enter N/A if not applicable)

15. Did your Medical School have special "paths" or "tracks"?

j Yes
k
l
m
n
j No
k
l
m
n

16. If you participated in a special "track" or "pathway" at your Medical School, please
indicate that "track" or "pathway" below.

17. What year did you graduate from Medical School?

18. Did you enter residency in the academic year immediately following graduation from
medical school?

j Yes
k
l
m
n
j No
k
l
m
n

19. If you did not enter Residency immediately after graduating from Medical School, how
did you spend the time in between?
5
6  

Pre­Medical Education

20. Please enter the following information for any education in addition to Medical School.
School 1:
Name
City
State
Country
Study Area
Degree Conferred
Start Year
End Year

21. School 2 (if applicable):
Name
City
State
Country
Study Area
Degree Conferred
Start Year
End Year

22. School 3 (if applicable):
Name
City
State
Country
Study Area
Degree Conferred
Start Year
End Year

23. School 4 (if applicable):
Name
City
State
Country
Study Area
Degree Conferred
Start Year
End Year

Pre­Medical School Experience

24. Did you take time off between college and medical school?

j Yes
k
l
m
n
j No
k
l
m
n

25. If yes, what did you do during that time?
5
6  

Residency Application

26. What were your primary reasons for choosing your Residency Program?
5
6  

Career Plans

27. Are you planning to do additional residency or fellowship training after this residency
training program?

j Yes
k
l
m
n
j No
k
l
m
n

j Not Yet Decided
k
l
m
n

28. If yes, what additional residency/fellowship training are you planning after this
residency training program?

29. Do you know where you want to work following all residency/fellowship training?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

30. If yes, where do you hope to work after completing your residency/fellowship training
program? Complete as much as you know.
City/Town:
State:

6

Country:

31. Please indicate the setting(s) in which you plan to work after the completion of your
residency/fellowship training. Choose all that apply.
c Large City (Population 500,000 of More)
d
e
f
g
c Suburb of a Large City
d
e
f
g

c City of Moderate Size (Population 50,000 to 500,000)
d
e
f
g
c Suburb of Moderate Size City
d
e
f
g

c Small City (Population 10,000 to 50,000 ­ other than suburb)
d
e
f
g
c Town (Population 2,500 to 10,000 ­ other than suburb)
d
e
f
g
c Small Town (Population less than 2,500)
d
e
f
g
c Rural/Unincorporated Area
d
e
f
g

c Undecided or No Preference
d
e
f
g

32. Do you plan to locate your practice in an underserved area?

j Yes
k
l
m
n
j No
k
l
m
n

j Undecided
k
l
m
n

33. If you plan to locate your practice in an underserved area, please indicate the likely
location.
j Rural community
k
l
m
n

j Inner­city community
k
l
m
n

Other (please specify) 

34. Regardless of location, do you plan to work primarily with minority populations?

j Yes
k
l
m
n
j No
k
l
m
n

j Undecided
k
l
m
n

35. If you plan to work primarily with minority populations, please indicate the minority
population you intend to work with. Select all that apply.
c Black/African American
d
e
f
g
c Hispanic/Latino
d
e
f
g

c Native American
d
e
f
g
c Asian
d
e
f
g

Other (please specify) 

Student Debt

36. Did you receive a scholarship with a service requirement for medical school (for
example, National Health Service Corps Scholarship)?

j Yes
k
l
m
n
j No
k
l
m
n

37. If you did receive a scholarship with a service requirement, please indicate the name of
the scholarship

38. Do you plan to apply for National Health Service Corps (NHSC) or other loan
repayment program with a service requirement?

j Yes
k
l
m
n
j No
k
l
m
n

j Undecided
k
l
m
n

j Don't Qualify
k
l
m
n

j Unaware of such programs
k
l
m
n

39. What is the total amount of your outstanding educational loans for your
college/premedical education? (Enter "0" if you have no outstanding educational loans)

40. What is the total amount of your outstanding educational loans for your medical
education? (Enter "0" if you have no outstanding education loans for medical school)