Application for Graduation and Questionnaire

Diploma Information

Graduates who participate in commencement will receive their degree upon completion of the ceremony. Graduates who are not participating will have diplomas mailed upon confirmation of the completion of all degree requirements by the dean. All financial obligations to the University must be satisfied before diplomas will be released.
Name as your would like it to appear on your Diploma (Should match ECFMG documents)*
Provide the correct name to be stamped on your diploma certificate. Use capital and lower case letters and correct punctuation, accents, comas, apostrophe's as needed.
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Gown Order Form

Doctoral Tams, Tassels, and Hoods may be kept. Gowns must be returned at the end of the commencement ceremony.
Do you plan to participate in the commencement ceremony?*

YesNo
Gown Order Form (for graduates that are participating)

Graduation Fee

Graduation FeeCost of the diploma, mailing fees, and other administrative expenses associated with graduation and postgraduate services.

$750.00

Enter coupon

Total

$0.00

I hereby grant permission to the University of Health Sciences Antigua to reproduce any portion of photo images or video that have been taken at the commencement ceremony to be used for the purpose of promotional publications, which can include but is not limited to, books, cards, calendars, invitations, and websites without any more compensation or recognition given to me. Furthermore, I grant creative permission to alter the photograph(s). I do not grant permission to resale or use the photographs in a manner that would exploit or cause malicious representation toward me or my company and associates.
Signature*

Clear
Any payments made in accordance with this form submission shall, once they are paid, not be refundable nor creditable for any reason whatsoever.
Should be Empty:

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not Applicable
Basic science coursework had sufficient illustrations of clinical relevance.
Required clinical experiences integrated basic science content.

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not Applicable
Basic science coursework had sufficient illustrations of clinical relevance.
Required clinical experiences integrated basic science content.
Basic science content objectives were made clear to students.
Basic science content was sufficiently integrated.
Basic science content objectives and examination content matched closely.
Basic science content had sufficient illustrations of clinical relevance.
Basic science content provided relevant preparation for clerkships.

	Poor	Fair	Good	Excellent	Not Applicable
Biochemistry
Biostatistics and epidemiology
Genetics
Gross anatomy
Immunology
Introduction to Clinical
Medicine/Introduction to the Patient
Histology
Microbiology
Neuroscience
Pathology
Pharmacology
Physiology
Behavioral science
Pathophysiology of disease

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I received clear learning objectives for the clerkship.
My performance was assessed against the learning objectives.
I had an opportunity to follow a variety of different patients (with different medical conditions) on the clerkship.
Faculty provided effective teaching during the clerkship.

	Yes	No
Oral Examination
Assessment by faculty member
Assessment by resident physicians
Case simulation using standardized patient(s)
Objective Structured Clinical Examination (OSCE)
Computerized case simulations

	Inadequate	Appropriate	Excessive
Patient interviewing skills
Physical examination skills
Diagnosis of disease
Clinical reasoning
Management of disease
Care of hospitalized patients
Care of ambulatory patients
Health maintenance
Long-term health care
Continuity of care
Physician-patient communication skills
Physician-patient communication skills with proper use of interpreter as needed
Physician-physician communication skills
Teamwork with other health professionals
Diverse populations health care
Cultural competence
Ethical decision making

	Inadequate	Appropriate	Excessive
Interpretation of clinical data and research reports
Conducting systematic literature review
Interpretation of laboratory results
Decision analysis

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
My knowledge or opinion was influenced or changed by becoming more aware of the perspectives of individuals from different backgrounds.
The diversity within my medical school class enhanced my training and skills to work with individuals from different backgrounds.
My knowledge of the impact of the social determinants of health on health care and health disparities.

	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
I am confident that I have acquired the clinical skills required to begin a residency program.
I have the fundamental understanding of common conditions and their management encountered in the major clinical disciplines.
I have the communication skills necessary to interact with patients and health professionals.
I have basic skills in clinical decision making and the application of evidence based information to medical practice.
I have a fundamental understanding of the issues in social sciences of medicine (e.g., ethics, humanism, professionalism, organization and structure of the health care system).
I understand the ethical and professional values that are expected of the profession.
I believe I am adequately prepared to care for patients from different backgrounds.

	Never Used	Very Satisfied	Satisfied	Neutral	Dissatisfied	Very Dissatisfied
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Diploma Information