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Student Information for the Public/Community Project:

Student Name:       Last Name     First Name     Middle Initial        Local Address:       Street     Apt. No.     City:     State:     Zip Code:     Home Phone:     Pager:     E-mail Address:                  Please complete the following questionaire to provide information about you for statistical tracking purposes only.     1.  Gender :  Male  Female   2.  Your geographical background?  Rural  Urban   3.  Significant Other geographical background?  Rural  Urban   4.  What type of practice are you thinking about after your medical training?  Primary Care  Non-primary care   5.  Geographical Setting?  Rural  Urban   6.  Do you plan to practice in Utah?  Yes  No   7.  Your ethnic background?  Asian American  Native American  Hispanic  African American  Caucasian  Pacific Islander   Other   8.  Are you from a disadvantaged background?  Yes  No     If yes, please specify :  Poverty  Ethnic  Medically Underserved   9.  Date of Birth :    Example: 11/18/1947   10.  Are you a National Service Corps Scholar?  Yes  No   11.  List languages you speak fluently other than English :