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Medical Student Biographical Form
Questions marked with a * are required
Today's Date
Contact Information
Date of Birth
City of Birth
Gender
Race/Ethnicity
Marital Status 
Spouse's Information (if applicable)
Medical School Information
Medical Student Level (M3 or M4)
Medical School Category (U.S. Allopathic, U.S. Osteopathic, or International Medical School)
Name of Medical School
Medical School City and State
For UT Students, check if you have Special Testing Accommodations (If you are a UT Student and will take end of clerkship shelf exams, check if you have been approved by SASSI for Special Testing Accommodations.)
Check if you are approved for extra testing time
Check if you are approved for separate testing room
Check if you are approved for both extra time and separate testing room
Rotation Information
List rotations you will be doing in Chattanooga (in order).
First Rotation Start Date
Anticipated End Date in Chattanooga
Prior location/rotation before coming to Chattanooga
Advise if any recent/known exposure or symptoms of COVID-19.
Emergency Information and Contacts
Medical Conditions (List any medical conditions about which we should be aware during your rotation or enter N/A.)
Emergency Contact
Living Arrangements in Chattanooga
Are you living in the student apartments at Hayden Place Apartments in Chattanooga while rotating  in Chattanooga?
Local Address and Phone where you are living in Chattanooga if not at Hayden Place.
Do you have friends or family in the Chattanooga area?
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