Center for Clinical Epidemiology and Biostatistics - University of

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					                                 The University of Pennsylvania School of Medicine
                          Masters of Science in Health Policy Research Program Application

Please read the instruction sheet carefully for details on how to complete and submit the application and for
details on additional required documentation. If you have any questions regarding this application please
see the contact information at the end of this form.

                                                     Personal Information

First Name:                                                       Last Name:
        SS#:            Last Four Digits Only                   Date of Birth:
   Address:                                                Phone Numbers:            Phone type
                                                              Double click on        Phone type
                                                            “Phone Type” for
                                                                     options         Phone type
Citizenship:                                             If not a US citizen, are you a Permanent Resident?

Please indicate your current Penn affiliation: Select One Other (if not in list):
(if you answered “Not Affiliated”, please skip to Application Details below)
               Penn Affiliation Title:
                         Department:                                            Location:
Department Business Administrator:                                             BA Phone:

                                                      Application Details
   Year of Desired Enrollment:           2008-2009

Optional: The University of Pennsylvania seeks to draw students from diverse backgrounds. The information
requested below will be used to evaluate the effectiveness of our recruitment efforts and to facilitate selection of a
diverse student body. This information is confidential and completely voluntary. Answering the questions or the
omission of an answer will not influence the application review process. Please identify the group(s) in which you
would include yourself.

Gender:      Select one
Ethnicity: Are You Hispanic or Latino?          Select one                     Race: Select one
                        If more than one race please specify:
                                                 Educational Background

Please list all higher education schools attended in chronological order (do not enter “refer to cv”)
                                                 Dates                                                Graduation
       Institution/Location                     Attended            Degree            Major              Date                GPA

Test Scores: A GRE or MCAT score is required for consideration in the program. If you have not completed either for these
tests, you must request a waiver from the requirement. The waiver request must include justification for why you think you
should not have to take the GRE or MCAT. The waiver request must either precede or accompany this application.

GRE              Date taken:
Verbal           V%                        Quantitative t         Q%                 Analytical          A%

MCAT             Date taken:
Verbal                           Physical. Science                     Writing                Biology

If you have MCAT scores that do not fit this format, please provide score information here:

Post Graduate Training: Please list any post-graduate training including internships, residency, fellowships and other
MCAT Notes:

    Title                    Institution/Location                           Specialty                            Dates

Academic Honors and Honorary Societies

                                        Title                                                             Date

                                                      Work Experience

Please include all relevant research experiences (whether laboratory based or clinical) and health policy experiences
(full or part-time)

                 Position                                   Institution (name and location)                          Dates

                                                 Board Certification Status

Are you board eligible?        Select

    Board :                               Have you taken the exam?         Select           Date of Certification:

Please list the names, titles, and institutions of three individuals who have known you professionally whom you have
asked to send provide reference letters. One should be the Director of your current program.

Name:                                     Title:

   Institution:                           Phone:                                Email:

Name:                                     Title:

   Institution:                           Phone:                                Email:

Name:                                     Title:

   Institution:                           Phone:                                Email:

Additional Documentation Requested:
    A personal statement listing your research interests and career objectives (no more than two double spaced
    Official transcripts from all degree granting institutions you have attended. Other coursework transcripts are
       also encouraged. These must be sent directly to our office from the institution to be considered official.
    Official GRE or MCAT test score results. While you will report your scores on the application form, official
       scores should be sent from the testing agency.
    A curriculum vitae including a list of publications (if applicable)
    Three reference forms with accompanying reference letters. The reference report forms are attached in a
       separate document. Each referee should be sent the form electronically so they can submit it to our offices
    A photo of your self, submitted electronically to the Education Programs Office – requested but not required

    By checking this box, you are attesting to the accuracy and validity of the information provided in this
application. The application will not be accepted without a check mark in this box. Any falsified information
will result in immediate disqualification for consideration for admission or withdrawal from the Program if
admission has already occurred.

If you have questions regarding these application materials, or the status of your application, please contact

David A. Asch, MD
Executive Director, Leonard Davis Institute of Health Economics
University of Pennsylvania
3641 Locust Walk
Philadelphia, PA 19104-6218

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