Tennessee Area Health Education Center Community Based Student Education Student Form

7-Digit ID (TN AHEC Office Use Only)

TN AHEC Center Code: (TN AHEC Office Use Only)

Activity Code: (TN AHEC Office Use Only)

PERSONAL INFORMATION

FIRST NAME:

MIDDLE INITIAL:

LAST NAME:

STREET ADDRESS:

CITY:

COUNTY:

STATE:

ZIP CODE:

PHONE NUMBER:

PREFERRED E-MAIL ADDRESS:

PERMANENT E-MAIL

In which kind of community did you grow up?

COMMUNITY TYPE:

DEMOGRAPHIC INFORMATION

GENDER:

DATE OF BIRTH:

Date

ETHNICITY:

RACE: (check all that apply)

VETERAN STATUS: (check only one)

Can you answer yes to any of the following questions?

- You are (or will be) the first generation in your family to attend college.- You have or currently receive Scholarship or Loan for Disadvantaged Students.- While growing up, you or your family ever participated in federal or state programs (such as free or reduced school lunch, subsidized housing, food stamps, Medicaid, etc.)- While growing up, you lived where there were few medical providers at a convenient distance.

STUDENT SURVEY

Current Classification?

Anticipated Graduation Date:

Date

Are you enrolled in a dual degree program? (If yes, specify)

Specify program name:

I intend/would like to work in a primary care setting such as a Family Medicine, Gen Internal Medicine, or Gen Pediatrics clinic.

Plan to work in primary care setting

I intend/would like to enter a health career as a primary care clinician such as, a Family Medicine doctor, Gen Internal Medicine doctor, Physician Assistant, etc.

Primary Care Health Career:

If yes, which primary care specialty?

I intend/would like to work with people who are medically underserved - those that have barriers to Healthcare.

Work with the underserved:

I intend/plan/would like to work in rural areas (not big cities).

Work in rural area