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Medical Student Biographical Form

Questions marked with a * are required

Today's Date

Contact Information

Last Name

First Name

Middle Name

Preferred Name

Email Address

Phone Number

Address

Address Line 2 (if needed)

City

State

Zip Code

Date of Birth

City of Birth

Gender

Male

Female

Race/Ethnicity

Marital Status

Spouse's Information (if applicable)

Spouse's Last Name

Spouse's First Name

Phone

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.)

Yes

Check if you are approved for extra testing time

Yes

Check if you are approved for separate testing room

Yes

Check if you are approved for both extra time and separate testing room

Yes

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

Emergency Contact Name

Relationship

Phone

Street Address

City

State

Zip Code

Living Arrangements in Chattanooga

Are you living in the student apartments at Hayden Place Apartments in Chattanooga while rotating in Chattanooga?

Yes

No

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?

Yes

No

UTHSC College of Medicine, Chattanooga | 960 East Third Street, Suite 100, Chattanooga, TN 37403 | 800.947.7823 ext. 6956

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