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:*

Urban/Inner CitySuburbanRuralFrontier

DEMOGRAPHIC INFORMATION

GENDER:

FemaleMale

DATE OF BIRTH:

Date

ETHNICITY:*

HispanicNon-Hispanic

RACE: (check all that apply)*

VETERAN STATUS: (check only one)*

Active Duty MilitaryReservistVeteran (prior service) - an individual discharged after serving a period of 90 days or moreVeteran (retired) - an individual discharged after serving a period of 20 years or more OR due to medical statusNot a Veteran - an individual who has never served in the uniformed services OR was discharged before serving 90 days or more

Can you answer yes to any of the following questions?*

YesNo

- 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?

1st yr2nd yr3rd yr4th yr

Anticipated Graduation Date:

Date

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

YesNo

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*

YesNoUnknownNot Applicable

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:*

YesNo

If yes, which primary care specialty?*

Family MedicineGen. Internal MedicineGen. PediatricsOB/GYN

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

Work with the underserved:*

YesNo

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

Work in rural area*

YesNo