Student Biographical I Nformation Form

Biosketch Template 1 STUDENT BIOGRAPHICAL INFORMATION FORM (BIOSKETCH)

Name: Phone: 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 for ERAS. We recommend that you keep this updated, including scholarships, research positions, etc. Please list dated information chronologically. Handwritten forms cannot be used. Please see Ginny Atwell (924-2133) in the Office for Student Affairs, Medical Education Building, Suite 3188 if you need assistance.

UNDERGRADUATE EDUCATION:

1. List all undergraduate colleges attended. Include double majors, minors, etc. List Chronologically: College/University Dates Major Minor Degree

POST-BACCALAUREATE CAREER INFORMATION: (excluding graduate school)

2. 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)

GRADUATE EDUCATION: (excluding medical school)

3. List all graduate schools attended List Chronologically: College/University Dates Major Minor Degree

MEDICAL EDUCATION: Biosketch Template 2

4. Please indicate if you are in a Dual Degree Program. (MD/PhD, MD/MBA, MD/MPH)

Degree Program

5. List all honors and awards received. 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)

6. List all research experience. Please make this a brief summary (1-2 sentences). List Chronologically: Dates, Location & Topic Supervisor (brief; 1-2 sentences) (include DEGREE) (ex: John C. Doe, M.D., Ph.D.)

7. List all research publications. Please make this a brief summary (1-2 sentences). List Chronologically: Dates, Location & Topic Publications and/or Supervisor (brief; 1-2 sentences) Presentations (include DEGREE) (Author/s, Journal Title, Yr, (ex: John C. Doe, Vol., Pgs.) M.D., Ph.D.) ex: Journal of Neurochemistry (1998;73:217-232)

Biosketch Template 3 8. List all research posters, abstracts, and oral presentations. Please make this a brief summary (1-2 sentences). List Chronologically: Dates, Location & Topic Publications and/or Supervisor (brief; 1-2 sentences) Presentations (include (Author/s, Journal Title, Yr, credentials) Vol., Pgs.) (ex: John C. ex: Journal of Doe, M.D., Neurochemistry Ph.D.) (1998;73:217-232)

9. List all extracurricular, leadership & community activities. 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)

10. List all employment during your undergraduate education through medical school. Include summer jobs, dates of employment, etc. List Chronologically: Employment Date(s)

12. Memberships in Professional and Student Societies: List Chronologically: Professional & Student Memberships Date(s)

Biosketch Template 4

PERSONAL INFORMATION:

School of Medicine Faculty Advisor:

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

Couples Matching: Yes No: With: ______

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)

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

Is there some personal information regarding your background/achievements that you would like us to know?