SCP/CBE Student Information  In preparation for your interview with the Student Continuity Practice (SCP) office, please complete the form below. The information will be used to assist us in assigning you an SCP site and Principles of Medicine (PCM) core group. If you have any questions, please contact the SCP office (860-679-4993). Please complete by August 3, 2008.
Please use the tab key (not <Enter>) to move from one question to the next.
First Name:                     Last Name:
Telephone:
E-mail Address:
Home Address:               City:        State:      Zip:
Local  Address (during Med School):               City:        State:       Zip:   Phone during medical school:
Please record all paid or volunteer work experience (include community service):
Job/position	Duties/responsibilities	Check if applicable:
		Patient care experience	Paid	Teaching involved
		yes	yes	yes
		yes	yes	yes
		yes	yes	yes
		yes	yes	yes
		yes	yes	yes
SCP sites include internal medicine, pediatrics and family medicine.  If you have a strong preference for any of these options, please rank them accordingly order (1 for highest) and tell us why.
Specialty	Rank
Family Medicine	select one: 1 2 3
Internal Medicine	select one: 1 2 3
Pediatrics	select one: 1 2 3
Other options are the type of practice community.  Again, please rank your preferences and tell us why.
Type of Community	Rank
Urban	select one: 1 2
Suburban	select one: 1 2
What is most important to you, Discipline or Location?   select one: Discipline Location Please explain why:
Do you have a car, or access to a car on a weekly basis for SCP?   select one: Yes No
We try to match students with an SCP that is within 1 hour from the Health Center.  Are there towns or regions of the state that would be convenient or desirable for you to travel, because you have relatives or friends there?   select one: Yes No            If yes, where?
What would you rate your interest in a primary care career?     select one: Very Interested Somewhat Interested Neutral Somewhat Uninterested Very Uninterested
Please rate your skill level in speaking, writing and reading in the following languages.  (1=bilingual or very fluent, able to conduct an interview, translate information, read easily; 2= functional knowledge, able to converse, and function in everyday situations; 3=introductory courses, basic comprehension)
Language	Ranking for Skill Level
Spanish	None 1 2 3
French	None 1 2 3
Polish	None 1 2 3
Russian	None 1 2 3
Hindi	None 1 2 3
Sign Language	None 1 2 3
Other:	None 1 2 3
Other:	None 1 2 3
Can you conduct an interview in the language which you are proficient, with the understanding that you might not have the medical terminology at this point? select one: Yes No
In any of your volunteer or work experiences, have you had the opportunity to learn about people from ethnic and cultural backgrounds that are different from your own?   select one: Yes No If yes, please describe: How might this experience impact your future interactions with patients?
Are you interested in an international experience while in medical school?   select one: Yes No Please describe any previous international experiences you have: