supplemental for stanford 2015

8/15/2019 Supplemental for Stanford 2015

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Primary Care Associate ProgramStanford University School of Medicine and Foothill College

1215 Welch Rd. Mod!le " Palo Alto CA #$%&5'5$&(

Supplemental Application for the Class of 2018

S!))lemental A))lication d!e in the )rogram *y +C, 1 2&15Fee- 5& )aid to S,A/F+R0 U/3RS,4 and *y Cashier Chec orMoney +rder

CASPA Number: _________________________

First Name: ______________________________

Middle Name: ______________________________

ast Name: ______________________________

Social Securit! Number: ______________________________

Startin" #ith the most recent$ list all medicall!%related trainin" recei&edoutside of a re"ionall!%accredited institution'

Name ofSchool

ocation(Cit!$ State$)ip*

+atesAttended(Mo,-r % Mo,-r*

Ma.or,Minor +e"reeConferredand +ate/ecei&ed

a&e !ou e&er applied to the Stanford PCAP Pro"ram -es No

f !es$ #hat !ear (s*_______________________________________

Section

Section

1


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1' Medical 34perience:

A minim!m of %&&& ho!rs of direct )atient'care e6)erience m!st *e

com)leted in the USA and m!st *e com)leted *y +cto*er 1 2&15 'ours accrued$ as a student in a trainin" pro"ram cannot be counted'Startin" #ith the most recent$ list all medicall!%related &oluntar! or paidpositions held' 5he #or6sheet pro&ided corresponds to the informationpro&ided in this section' f necessar!$ use a supplemental pa"e as acontinuation of this form' 0o not refer revie7er to res!me.

3m)loyer Address andPhone

8o* ,itleMo94r'Mo94rSetting ofPractice :i.e.Clinic;os)ital<

0escri*e RolesRes)onsi*ilities and S)eci=cSills /eeded nvolving0irect Patient Care. ncl!deyo!r sco)e of )ractice.

2' ours of direct patient care responsibilit! (Please use the lin6 to accessthe #or6sheet*:

Full%time - >>>>>>>>>>>>>>>>>>>>>>>>>>>>>> Part%time: ________________________ (5otal months and hours* (5otalmonths and hours*

Worsheet sho7ing Clinical ;o!rs Calc!lationsEXAMPLE ONLY (use "PCAP worksheet" for your information)Submit a completed cop! #ith !our application' Start table #ith the most recentinformationpcap'stanford'edu,admissions,7or6sheet%PAand+PC'4ls4

3m)loyersStart0ate

:M9094<

3nddate

:M9094<

? of Wee

s

? of ;o!rsWored9W

ee

3st.@d of 0PC

0PC;o!r

s

0'0 0'0

0'0 0'0

0'0 0'0

0'0 0'0

Section

2

http://pcap.stanford.edu/admissions/Worksheet-GPAandDPC.xlsxhttp://pcap.stanford.edu/admissions/Worksheet-GPAandDPC.xlsx


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0'0 0'0

S!m ,otal &.&

9 ours #or6ed ,7ee6 must represent real estimate of the a&era"e time #or6ed per #ee6

3st'd ; of +PC Contact (should be a #hole number bet#een 0 % 100* < ; of time !ou actuall! #or6ed #ithpatients$ not includin" transportation$ idle or administrati&e time

+PC ours < (9 of 7ee6s* = (9 of ours #or6ed , #ee6 * = (3stimated ; of +PC Contact , 100'

>' +o !ou currentl! hold a license or certi?cate in a medicall!%relatedprofession -es , No

5!pe of license,certi?cate _________________________ icense,Certi?cate 9 _________

+ate license #as ?rst issued ________________________ 34piration date ______________

@' as an! license and,or certi?cate been sub.ect to disciplinar! action b! are"ulator! a"enc! -es No

f !es$ icense,Certi?cate __________________________________-ear ____________

Bf yes )lease descri*e the circ!mstances and the resol!tion.

' a&e !ou e&er been terminated for cause b! an emplo!er -esNo

f !es$ 3mplo!er __________________________________ -ear ___________

Bf yes )lease descri*e the circ!mstances and the resol!tion.

>


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1' Communit! Ser&ice:

Startin" #ith the most recent$ list all &olunteer communit! ser&iceacti&ities' 0o not re)eat )ositions listed !nder medical e6)erience'

f necessar!$ use a supplemental pa"e as a continuation of this form'

Comm!nity+rganiationS!)ervisor /ameAddress and ,ele)hone/!m*er

PositionMo94r'Mo94r,otal ;o!rs

0escri*e Deadershi)Roles Res)onsi*ilitiesand S)eci=c Sills/eeded

Section B

@


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,otal n!m*er of ho!rs-

2' /esidence nformation:

Startin" #ith the most recent$ list the t!pes (e'"'$ rural$ suburban$ urban$inner cit!$ lo# income$ reser&ation* and names of communities !ou ha&eli&ed in and !our dates of residence' se a supplemental pa"e$ if necessar!'

,y)e of Residence City State 0ates of Residence:Mo94r'Mo94r<

>' n #hich t!pe of communit! or in #hat "eo"raphic location #ould !ouprefer to #or6 after "raduation from the PA pro"ram (circle all that appl!*

/ural rban o# income

Suburban nner cit! /eser&ation

@' 7e are interested in !our commitment and "oals as a PA' Please ta6e amoment to reDect and #rite !our responses to the follo#in" Euestions'

• 7h! are !ou appl!in" speci?call! to the Stanford Pro"ram

• 7hat ma6es !ou a "ood candidate to the Stanford Pro"ram

• Commitment and bac6"round e4perience

• bstacles and challen"es

• Future "oals and ambitions(Ma4imum of 000 characters (not #ords*$ in 12 point font or lar"er$ or an

eEui&alent*


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' ,3C;/CAD S,A/0AR0S E Please read and sign.:Re!ired< 5he abilities and s6ills #hich students must possess in order to complete thetrainin" associated #ith the Pro"ram are referred to as 5echnical Standards' 5hese essential abilities are a "roup of minimal ph!sical and co"niti&eabilities as #ell as suGcient mental and emotional stabilit! to con?rm thatstudents are able to complete the entire course of stud!$ participate full! in

all aspects of PA trainin"$ and be deplo!able as competent PAs$ #ith or#ithout reasonable accommodation' Competenc! in technical standards #illbe assessed re"ularl! throu"hout the Pro"ram' See chec6list in appendi4'

5he Pro"ram has the ethical responsibilit! for the safet! of patients #ith#hom students and "raduates #ill come in contact$ and to the public toassure that its "raduates can become full! competent PAs' 5hus$ it isimportant that persons admitted to the Pro"ram possess the intelli"ence$

H


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inte"rit!$ compassion$ humanitarian concern$ and ph!sical and emotionalcapacit! necessar! to practice medicine' Students must &erif! that the!meet these 5echnical Standards prior to or at the time of matriculation to thePro"ram and maintain them durin" their PCAP trainin"' Students areobli"ated to alert the Pro"ram of an! chan"e in their abilit! to ful?ll the

5echnical Standards' St!dents are s!*Gect to dismissal if they do nothave minimal )hysical or cognitive a*ilitiesH s!Icient mental oremotional sta*ility to com)lete the entire co!rse of st!dy)artici)ate f!lly in all as)ects of PA training or *e de)loya*le ascom)etent PAJs :7ith or 7itho!t reasona*le accommodation


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5echnical Standard B: ntellectual%Conceptual$ nte"rati&e and Luantitati&eAbilities

Students must be able to learn throu"h a &ariet! of modalities includin"$ butnot limited to$ classroom instruction small "roup$ team and collaborati&eacti&ities indi&idual stud! preparation and presentation of reports and use

electronic technolo"!' Students must ha&e the mental capacit! to assimilateand learn a lar"e amount of comple4$ technical and detailed information inorder to formulate dia"nostic and therapeutic plans'

5echnical Standard B: eha&ioral and Social AttributesStudents must ha&e the emotional stabilit! to function eIecti&el! understress and to adapt to an en&ironment that ma! chan"e rapidl!$ #ithout#arnin"$ and,or in unpredictable #a!s' 5he! must accept responsibilit! forlearnin"$ e4ercisin" "ood .ud"ment$ and promptl! completin" allresponsibilities durin" their academic trainin" as #ell as attendant to thedia"nosis and care of patients' 5he! must understand the le"al and ethical

standards of the medical profession' Students must be able to #or6eIecti&el!$ respectfull! and professionall! as part of the educational andhealthcare team$ and to interact #ith instructors and peers$ patients$ patientfamilies$ and health care personnel in a courteous$ professional$ andrespectful manner' Students must be able to contribute to collaborati&e$constructi&e learnin" en&ironments accept constructi&e feedbac6 fromothers and ta6e personal responsibilit! for ma6in" appropriate positi&echan"es'

5echnical Standard B: 3thical and e"al StandardsStudents must be able to understand the basis and content of both "eneraland medical ethics' 5he student must possess attributes that includecompassion$ empath!$ altruism$ inte"rit!$ responsibilit!$ and tolerance'Student must be able to reco"niJe limitations in their 6no#led"e$ s6ills andabilities and to see6 appropriate assistance #ith their identi?ed limitations'Students #hose performance is impaired b! abuse of alcohol or othersubstances are not suitable candidates for admission$ promotion$ or"raduation' n addition$ should the student be char"ed or con&icted of an!misdemeanor or felon! oIense #hile in the Pro"ram$ the! a"ree toimmediatel! notif! the Pro"ram as to the nature of the le"al diGcult!' Failureto disclosure prior or ne# oIenses can lead to disciplinar! action that ma!include dismissal' Students must meet the le"al standards to be licensed asa ph!sician assistant in the State of California'

Adapted from Stanford School of Medicine Technical Non-Academic Standard,http://med.stanford.edu/md/admissions/technical_standards.html, Accessed May 20, 2009; updated May 16, 201

ha&e read the PCA Pro"ramOs 5echnical Standards and a"ree that candemonstrate the abilities identi?ed'

Printed /ame >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

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Signat!re >>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 0ate >>>>>>>>>

supplemental for stanford 2015

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