Checklist for BHT
Dear students, this form is to gather information on your progress of the BHT through the four years of medical school. You may either pursue the BHT traditional pathway or the newly developed BHT/CET Dual Track. Also, a good thing to remember, it is important that you update this form every year as I utilize this form to determine credits earned to complete the track in year 4.
Date *
MM
/
DD
/
YYYY
Last Name *
Your answer
Middle Initial
Your answer
First Name *
Your answer
Oral Proficiency Level
PID
Please enter your student PID
Your answer
Entering Class *
Please indicate the year you entered SOM
Your answer
Completed Courses (Traditional/Dual)
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
Elective #1
List complete name of clinic
Your answer
Elective #1
List complete physical address of clinic
Your answer
Elective #1
List city where clinic is located
Your answer
Elective #1
List complete name of physician
Your answer
Elective #1
List phone number of clinic
Your answer
Elective #1
Choose closest estimate of Spanish-speaking patients seen in clinic
Elective #2
List complete name of clinic
Your answer
Elective #2
List complete physical address of clinic
Your answer
Elective #2
List city where clinic is located
Your answer
Elective #2
List complete name of physician
Your answer
Elective #2
List phone number of clinic
Your answer
Elective #2
Choose closest estimate of percent of Spanish-speaking patients in clinic
Elective #3
List complete name of clinic
Your answer
Elective #3
List complete physical address of clinic
Your answer
Elective #3
List city where clinic is located
Your answer
Elective #3
List complete name of physician
Your answer
Elective #3
List phone number of clinic
Your answer
Elective #3
Choose closest estimate of percent of Spanish-speaking patients seen in clinic
Attended Capstone Presentations
1
2
3
4
5
6
7
8
9
10
11
12
Bilingual Health Track
Global Health Track
Public Health Track
Rural Health Track
Met with advisor 2x/year
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