Checklist for BHT
Last Name
Your answer
Middle Initial
Your answer
First Name
Your answer
Oral Proficiency Level
Applicable to students starting in 2014 and beyond
PID
Please enter your student PID
Your answer
Entering Class
Please indicate the year you entered SOM
Your answer
Date
MM
/
DD
/
YYYY
Completed Courses
Please check those that you have completed
Summer Preceptorship #1
List complete name of clinic
Your answer
Summer Preceptorship #1
Check country
Summer Preceptorship #1
List complete physical address of clinic
Your answer
Summer Preceptorship #1
List city where clinic is located
Your answer
Summer Preceptorship #1
List complete name of physician
Your answer
Summer Preceptorship #1
List phone number of clinic
Your answer
Summer Preceptorship #1
Choose closest estimate of Spanish-speaking patients seen in clinic
Summer Preceptorship #2
List complete name of clinic
Your answer
Summer Preceptorship #2
Check Country
Summer Preceptorship #2
List complete physical address of clinic
Your answer
Summer Preceptorship #2
List city where clinic is located
Your answer
Summer Preceptorship #2
List complete name of physician
Your answer
Summer Preceptorship #2
List phone number of clinic
Your answer
Summer Preceptorship #2
Choose closest estimate of Spanish-speaking patients seen in clinic
Clerkship #1
List complete name of clinic
Your answer
Clerkship #1
List complete physical address of clinic
Your answer
Clerkship #1
List city where clinic is located
Your answer
Clerkship #1
List complete name of physician
Your answer
Clerkship #1
List phone number of clinic
Your answer
Clerkship #1
Choose closest estimate of Spanish-speaking patients seen in clinic
Clerkship #2
List complete name of clinic
Your answer
Clerkship #2
List complete physical address of clinic
Your answer
Clerkship #2
List city where clinic is located
Your answer
Clerkship #2
List complete name of physician
Your answer
Clerkship #2
List phone number of clinic
Your answer
Clerkship #2
Choose closest estimate of percent of Spanish-speaking patients in clinic
Clerkship #3
List complete name of clinic
Your answer
Clerkship #3
List complete physical address of clinic
Your answer
Clerkship #3
List city where clinic is located
Your answer
Clerkship #3
List complete name of physician
Your answer
Clerkship #3
List phone number of clinic
Your answer
Clerkship #3
Choose closest estimate of percent of Spanish-speaking patients seen in clinic
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms