ABCDEFGHIJKLMNOPQRSTUVWXYZAA
1
**To use this application record, select 'FILE' >> 'Make a Copy', so you are able to make a personal copy that it editable for you!
2
PERSONAL INFORMATION
3
4
Biographic Information Questions:
5
*Name (first, middle, last, suffix)
6
*Do you have any materials under a former legal name? (yes/no)​
7
*Legal Sex (male/female/decline to state)​
8
Gender Identity (See options --> )​
9
Gender Pronouns (See options -->)​
10
*Birth information (date, country, city, state, county)
11
12
13
Contact Information Questions:
14
*Current address (street, city, country, state, zip code, valid dates)
15
*Is your current address your permanent address? (yes/no)
16
*Preferred Phone Number
17
*Email Address
18
19
20
Citizenship Information Questions:
21
*U.S. Citizenship Status (See answer choices -->)​
22
*Country of Citizenship (If not U.S.)
23
*Do you have dual citizenship?​
24
*Legal State & Country of Residence
25
*How long have you been a resident of your state? (See options -->)​
26
*Do you have a U.S. Visa?​
27
Have you applied for and been accepted to DACA (Deferred Action for Childhood Arrivals)? (yes/no)
28
29
30
Race and Ethnicity Questions (optional):
31
Do you consider yourself to be of Hispanic/Latino origin?​
32
Are you of Arab, Middle Eastern, and/or North African origin?​
33
Race (See choices -->) ​
34
35
36
Environmental Factors (optional):
37
In what country/state/county/city did you spend the majority of your life, from birth to age 18?
38
What type of geographic area were you raised in? (See options -->)​
39
Description of childhood residency. (250 Character Limit)EXAMPLE: Grew up in a single family home within a lower-middle class suburb surrounding Orlando, Florida.
40
Do you feel that the area where you grew up was medically underserved? ​
41
Have you or members of your immediate family ever used federal or state assistance programs?​
42
What was the income level of your family during the majority of your life, from birth to age 18?​
43
Did you have paid employment prior to age eighteen?​
44
Were you able to contribute to the overall family income (as opposed to working primarily for your own discretionary spending money)?​
45
46
47
Other Information Questions:
48
*What is your first language?
49
*Have you ever had any certification, registration, license or clinical privileges revoked, suspended or in any way restricted by an institution, state or locality? (yes/no)
50
*Have you ever been disciplined by any college, university, or professional school for: (1) unacceptable academic performance (academic probation, suspension, dismissal, etc.) or (2) conduct violations? (yes/no)
51
*What is the type of geographic area where you were raised? (See options -->)​
52
*In which of the following specialty areas do you wish to work after graduation from PA school? Please select the option that best applies at this time. (Your response to this question below is not visible to programs and is used by the PAEA for recruitment planning purposes only.)​
53
Military Status (Active Duty/ Veteran/Reserve Member/Military Dependant/Not a member of the military/Other)
54
*Were you honorably discharged from the military? (Yes/No/I did not serve)
55
*Have you ever previously been enrolled as a student in a Physician Assistant program, Medical School (including foreign), or any health profession, including but not limited to DO, Dentistry, Physical Therapy, Occupational Therapy, Chiropractic, Podiatry, etc.? (Yes/No)
56
57
58
COVID-19 Question (optional)
59
Please describe how COVID-19 has impacted your pathway to becoming a Physician Assistant. The questions below will help you get started, but do not limit your responses to only these considerations.

Academic: Did your school move to an online-only curriculum? Were you able to interact with your professors? Did you have to leave an academic program stateside or abroad? Did your school require you to move to the Pass/Fail grading system? Did your original GRE exam get canceled or delayed? Were there Other academic barriers?

Professional: Did you hold a job? Did you have to go out and seek new job opportunities? Did you lose a job? Were there other financial or professional barriers that you faced?

Personal: Did you have to move out of a house or dorm? Did you have to cancel travel plans? Did you modify your planned experiences related to healthcare or volunteer opportunities? Did you seek out volunteer opportunities that arose from the crisis?		**Type or copy and paste response here. Character count will automatically update.**
60
Character Count (2500 character limit):84
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100