Prehealth Evaluation Form

Student Evaluation
Please check off which evaluator(s) you are CURRENTLY adding to this form: (IMPORTANT: Do NOT check off evaluators you have already added to the form. That information has already been saved, and can be viewed by clicking 'next" at the bottom of the page.)

Science Faculty 1Science Faculty 2Social Science/Humanities FacultyEvaluator documenting health care experience (at least 50 hours)Optional Evaluator - confirming researchOptional Additional EvaluatorOptional Additional Evaluator 2
NOTE: You already entered information for Science Faculty 1 previously ({scienceFaculty}). Checking this box again will resend an email to this evaluator.
NOTE: You already entered information for Science Faculty 2 previously ({scienceFaculty28}). Checking this box again will resend an email to this evaluator.
NOTE: You already entered information for Social Science/Humanities Faculty previously ({socialSciencehumanities}). Checking this box again will resend an email to this evaluator.
NOTE: You already entered information for Evaluator documenting health care experience ({evaluatorName}). Checking this box again will resend an email to this evaluator.
NOTE: You already entered information for Optional Evaluator - confirming research previously ({evaluatorName43}). Checking this box again will resend an email to this evaluator.
NOTE: You already entered information for Optional Additional Evaluator previously ({evaluatorName48}). Checking this box again will resend an email to this evaluator.
NOTE: You already entered information for Optional Additional Evaluator 2 previously ({evaluatorName108}). Checking this box again will resend an email to this evaluator.
If you are NOT adding any evaluator(s) at this time, but would like to change other information that you entered previously, please check below.

I am changing information that I entered previously
If you are not adding any evaluator(s) or changing any of your information at this time, do not check any of the options above. Press "next" to view the information you entered previously.

Student Information
Full Name*

First NameLast Name
Email*
example@albany.edu
ID Number*
e.g., 001234567
Health Profession
Area of Application*
Expected date of entry into professional school:*
Confidentiality Waiver
After careful consideration:*

I DO waive my right to review the following evaluationI DO NOT waive my right to review the following evaluation

Evaluator 1: A SCIENCE faculty who has taught you
Evaluator 1: A SCIENCE faculty who has taught you
Science Faculty 1 Name

First NameLast Name
Science Faculty 1 Email
example@example.com
Science Faculty 1 Title
Science Faculty 1 Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)

Evaluator 2: A SCIENCE faculty who has taught you
Evaluator 2: A SCIENCE faculty who has taught you
Science Faculty 2 Name

First NameLast Name
Science Faculty 2 Email
example@example.com
Science Faculty 2 Title
Science Faculty 2 Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)

Evaluator 3: A SOCIAL SCIENCE/HUMANITIES faculty who has taught you
Evaluator 3: A SOCIAL SCIENCE/HUMANITIES faculty who has taught you
Social Science/Humanities Faculty Name

First NameLast Name
Social Science/Humanities Faculty Email
example@example.com
Social Science/Humanities Faculty Title
Social Science/Humanities Faculty Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)

Evaluator 4: Documenting health care experience
Evaluator 4: Documenting a minimum of 50 hours of health care experience

Volunteer or paid work, shadowing/observation does not count for this requirement
Evaluator Name

First NameLast Name
Evaluator Email
example@example.com
Evaluator Title
Evaluator Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)

Evaluator 5: OPTIONAL - confirming research
Evaluator 5: OPTIONAL - confirming research
Evaluator Name

First NameLast Name
Evaluator Email
example@example.com
Evaluator Title
Evaluator Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)

Evaluator 6: OPTIONAL
Evaluator 6: OPTIONAL
Evaluator Name

First NameLast Name
Evaluator Email
example@example.com
Evaluator Title
Evaluator Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)

Evaluator 7: OPTIONAL
Evaluator 7: OPTIONAL
Evaluator Name

First NameLast Name
Evaluator Email
example@example.com
Evaluator Title
Evaluator Institution
Basis of Association with Student: (e.g., Course(s) and semester/year)
STUDENTS: Please click "submit" when you are finished filling out the above sections. An email will automatically be sent to the evaluators that you listed above.

Student Evaluation

Student Information

Health Profession

Confidentiality Waiver

Evaluator 1: A SCIENCE faculty who has taught you

Evaluator 2: A SCIENCE faculty who has taught you

Evaluator 3: A SOCIAL SCIENCE/HUMANITIES faculty who has taught you

Evaluator 4: Documenting a minimum of 50 hours of health care experience

Evaluator 5: OPTIONAL - confirming research

Evaluator 6: OPTIONAL

Evaluator 7: OPTIONAL

Section A.

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 1: A SCIENCE faculty who has taught you

Section B.

Science Evaluator 1

Section A.

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 2: A SCIENCE faculty who has taught you

Section B.

Science Evaluator 2

Section A.

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 3: A Social Science/Humanities faculty who has taught you

Section B.

Social Science/Humanities Evaluator

Section A

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 4: Letter documenting a minimum of 50 hours of health care experience

Section B.

Evaluator

Section A.

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 5: OPTIONAL - letter confirming research

Section B.

Evaluator

Section A.

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 6: OPTIONAL

Section B.

Evaluator

Section A.

Student Information

Health Profession

Student Confidentiality Waiver

Evaluator 7: OPTIONAL

Section B.

Evaluator