Name:
Student ID #:
BIOGRAPHICAL FORM 2017 version 1.0
7/28/2017
Before completing, carefully read the
Biographical Form Sample.
All forms must be typed.
To complete sections III and XVI, use an official or
unofficial transcript from each college you attended.
I. BACKGROUND INFORMATION
Professional program to which you are applying:
Are you applying to enter professional school in fall 2018?
Have you previously applied to medical or dental school?
If yes, when?
U.S. citizen or permanent resident?
If no, country of citizenship:
Texas resident?
If no, country of citizenship:
Ethnicity:
Native languages:
Other fluent languages:
Do you plan to complete a degree at UT Dallas?
If yes, what is your major?
When do you expect to graduate?
List the institution, year, and name of any degrees you have
already completed.
attach 4x6 photo here
A business-like photo with your face
clearly visible is most appropriate for
HPE and for professional schools.
Most home printers cannot produce good quality
photos. Use a “photo printer” and “photo paper,”
or have a print made for $0.25 at most drug stores.
II. YOUR EVALUATORS
HPE participants must solicit 3 letters of evaluation (max 5), including two from science professors.
Evaluator Name
Position
Relation to You
Health Professions Evaluation Biographical Form - Version 1.1
(7/28/2017) – Page 1 of 7
III. ACADEMIC SUMMARY.
 Use your transcripts to enter hours and grades in the GPA Calculator at www.utdallas.edu/pre-health/forms
 List all pre-college credits (i.e. from AP tests, dual credit courses) on the first line
 List all classes from all schools, including retakes.
Institution
Overall
GPA
Credits
BCPM
Science
Credits
BCPM
Science
GPA
“BCPM GPA” includes:
 BIO, including NSC
at
 CHEM
www.utdallas.edu/pre
 PHYS
health/forms
MATH, including STAT
Do not include courses
with other prefixes. Those
will be designated “other
science” or “non-science”
on the TMDSAS
application.
“Weighted averages”:
(Hours1*GPA1) + (Hours2*GPA2)
(Hours1+Hours2)
Total/Averages:
IV. STANDARDIZED TEST SCORES
Include all past tests and planned future tests.
Medical College Admission Test (MCAT)
Date
Total
Percentile
CPBS
Percentile
CARS
Percentile
BCLS
Percentile
PSBB
Percentile
“old version” MCAT score:
Dental Admission Test (DAT)
Date
PAT
QRT
RCT
BIO
Gen.
Che
Org.
Che
Total
Sci
AC
Avg
Health Professions Evaluation Biographical Form - Version 1.1
(7/28/2017) – Page 2 of 7
V. ACADEMIC RECOGNITION
List academic honors, awards and other recognitions received since beginning college to the present. Indicate the
Award Title, date received, city, country, state and a brief description of the award.
Activity/Honor
Description of Activity/Honor
Date
VI. NON-ACADEMIC RECOGNITION
List non-academic honors, awards and other recognitions received since beginning college to the present. Indicate the
Award Title, date received, city, country, state and a brief description of the award.
Activity/Honor
Description of Activity/Honor
Date
VII. LEADERSHIP EXPERIENCE
List any leadership roles or positions of responsibility held since beginning college to the present. Indicate the Role
Title, start date, end date, city, country, state and a brief description of the position.
Descriptions can be 300-characters long on TMDSAS.
Role Title
Description of Responsibilities
(including “hours/week” and “hours total”)
Dates
From To
/
/
/
/
/
/
/
/
/
/
VIII. EMPLOYMENT
List all jobs (paid work experience) held since graduating from high school to the present, including military service.
Indicate the employer, job title, when the job was held, start date, end date, city, hours worked per week, country,
state and a brief description of the job.
Health Professions Evaluation Biographical Form - Version 1.1
(7/28/2017) – Page 3 of 7
Description length may be limited on TMDSAS.
Job Title
Where Employed and Responsibilities
(including “hours/week” and “hours total”)
Dates
From
To
/
/
/
/
/
/
/
/
/
/
IX. RESEARCH ACTIVITIES
List any significant research activities (paid or volunteer) you have participated in since beginning college to the
present. Indicate the Research Activity Name, start date, end date, city, approximate hours worked per week, total
cumulative hours, country, state and a brief description of the research.
Descriptions can be 300-characters long on TMDSAS.
Role Title
(include your responsibilities, “hours/week” and “hours total”)
Supervisor
Dates
From To
/
/
/
/
/
/
X. HEALTHCARE ACTIVITIES
List any healthcare related community service, volunteer, employment OR shadowing experience you have
participated in since beginning college to the present. Indicate the Activity Name, start date, end date, city, hours
worked per week, total cumulative hours, country, state and a brief description of the activity.
Descriptions can be 300-characters long on TMDSAS.
Activity
Description
(including “hours/week” and “hours total”)
Dates
From To
/
/
/
/
/
/
/
/
/
/
Health Professions Evaluation Biographical Form - Version 1.1
(7/28/2017) – Page 4 of 7
XII. COMMUNITY SERVICE
List any non-healthcare related community service or volunteer activities you have participated in since beginning
college to the present. Indicate the Activity Name, start date, end date, city, approximate hours per week, total
cumulative hours, country, state and a brief description of the activity.
Descriptions can be 300-characters long on TMDSAS.
Activity
Description
(including “hours/week” and “hours total”)
Dates
From To
/
/
/
/
/
/
/
/
/
/
XIII. EXTRACURRICULAR AND LEISURE ACTIVITIES
List any significant extracurricular, leisure activities or hobbies you have participated in since beginning college to
the present. Indicate the Type of Activity, start date, end date, city, approximate hours per month, total cumulative
hours, country, state and a brief description of the activity.
Descriptions can be 300-characters long on TMDSAS.
Activity
Description
(including “hours/week” and “hours total”)
Dates
From To
/
/
/
/
/
/
/
/
/
XIV. PLANNED ACTIVITIES
Indicate future activities you plan on participating in between May 2016 and August 2017. This should include any
future employment as well as any future research, healthcare, community service, or extracurricular activities.
Indicate the Activity Type, start date, planned end date, city, total projected hours, country, state and a brief
description of the activity.
Activity
Description
(including “hours/week” and “hours total”)
Dates
From To
/
/
/
Health Professions Evaluation Biographical Form - Version 1.1
(7/28/2017) – Page 5 of 7
/
/
/
/
/
/
XV. ACADEMIC DISHONESTY AND/OR CRIMINAL ACTIVITY
Describe any actions taken against you for academic dishonesty, conduct violations, or criminal activity (including
felony and/or misdemeanor, other than minor traffic violations). Be as brief as possible while including relevant
details and applicable dates.
Essays?
TMDSAS allows you to write 3 essays that provide more details about your background and motivations.
MEDICAL PERSONAL STATEMENT
Explain your motivation to seek a career in medicine. Be sure to include the value of your experiences
that prepare you to be a physician. The personal statement is limited to 5000 characters, including spaces.
PERSONAL CHARACTERISTICS ESSAY
Learning from others is enhanced in educational settings that include individuals from diverse
backgrounds and experiences. Please describe your personal characteristics (background, talents, skills,
etc.) or experiences that would add to the educational experience of others. The personal characteristics
essay is limited to 2500 characters, including spaces.
OPTIONAL ESSAY
Briefly state any unique circumstances or life experiences that are relevant to your application. This is
not an area to continue your essay or reiterate what you have previously stated - this area is provided to
address any issues which have not previously been addressed. The optional essay is limited to 2500
characters, including spaces.
The optional essay is an opportunity to provide the admissions committee(s) with a broader picture of
who you are as an applicant. This essay is optional; however, HPAC strongly recommends that you
take advantage of this opportunity.
For details about application essays and how to approach them, explore the
Personal Statement Workshop.
Health Professions Evaluation Biographical Form - Version 1.1
(7/28/2017) – Page 6 of 7
XVI. TRANSCRIPT and CHRONOLOGICAL SUMMARY
For each box, write the names of activities that you listed above.
DO note how many hours per week or month that you participated in each activity.
DO denote any series of one-time events (i.e. “community service through AED”)
DO use abbreviations wherever you can do so clearly.
DO NOT denote one-time events separately
DO note where you took each class, if not at UT Dallas.
DO NOT list an activity in more than one column, even if you listed it in more than one
DO include the letter grade for each class you took.
section above. Instead, choose whichever column below is most appropriate.
If you entered activities in the Leadership section of the Biographical Form, include them in the chart below. Choose whichever column best matches each activity.
Sem
F'05
school
UTD
S'06
UTD/
CCCC
U'06
SMU
F'06
UTD/
CCCC
S'07
UTD
Classes
C- Chem I & lab A
A Macroecon.
A+ Col. Algebra
A RHET 1101
A RHET 1302
A Intro. Mgmt. Acct.
B+ Chem II & lab AA+ Precalculus
A Dance Apprec. (CCCC)
A Am. Govt. (SMU)
A U.S. Hist. (SMU)
A Bio I & wksp
B O.Chem I & lab A
A Calc I (CCCC)
A Intro. Fin. Acct.
A Bio II & wksp
A O.Chem II & lab A
A Calc II (CCCC)
Cred
hrs
14
GPA
3.57
13
3.77
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
6
4.00
13
3.70
15
4.00
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Young Muslims of North America, 4 hr/wk
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Young Muslims of North America, 4 hr/wk
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Publicity Comm Chair, Young Muslims, 4 hr/wk
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Publicity Comm Chair, Young Muslims, 4 hr/wk
High school tutor, 3 hr/wk
Healthcare or Research
U'07
F'07
UTD/
CCCC
A Biochem I & wksp
A+ Phys for Bios. II & lab
A World relig. (CCCC)
11
4.00
S'08
UTD
A Fin. Info. Mgmt.
A Organizaton Behavior
A Bio lab
A Biochem II & wksp
12
4.00
Other Extracurricular
Employment
Helped w/ billing for dad’s med. practice, 4
hr/month
Bollywood dance, 2 hr/wk
Community service, 22 hrs
Volunteer, nursing home, 8 hr/month since
3/08
Receptionist, home healthcare agency, 5 hrs/wk
Receptionist, home healthcare agency, 12-15
hr/wk
Receptionist, home healthcare agency, 12-15
hr/wk
Assistant Manager, home healthcare agency,
20 hr/wk
Health Professions Biographical Form
(7/28/2017) – Page 7 of 7