LMSA Chapter Report Form

Dear Esteemed LMSA Member,

Thank you for your valuable contributions to our organization. This form serves two key purposes:

a) To update your executive board leadership, delegate, and faculty contact information.

b) To complete the annual/biannual/quarterly chapter report form, as required by your regional bylaws.

LMSA National, encompassing five regions (Midwest, Northeast, Southeast, Southwest, and West), has distinct documentation requirements for National and Regional entities to maintain chapter status. Consequently, this form includes components for both, with potential overlap in questions.

Please note that if you are only updating delegate contact information, the process should be quick. However, if you are also completing a chapter report form, please allocate approximately 30 minutes to do so. It's important to remember that completion of the relevant sections is essential to maintain your active chapter status, as outlined in your by-laws.

For any questions related to completing this form, please reach out to your regional and/or national leaders as listed below.

¡Mil gracias!
LMSA National and Regional

Chapter Report Form

LMSA Region	Officer	Co-Director / Leader
Midwest	cdo.midwest@lmsa.net	director.midwest@lmsa.net
Northeast	cdo.northeast@lmsa.net	director.northeast@lmsa.net
Southeast	cdo.southeast@lmsa.net	director.southeast@lmsa.net
Southwest	membership.southwest@lmsa.net	director.southwest@lmsa.net
West	chiefinformationofficer@lmsa.net	southernceo@lmsa.net or northernceo@lmsa.net
National	cdo@lmsa.net	vp_operations@lmsa.net or president@lmsa.net

Select Region and Chapter

Please select your region and chapter from the dropdowns below.
My chapter is an*

LMSA ChapterLMSA Plus Chapter (undergraduate)
Region Report Form Statuses:
- Midwest: Active
- Northeast: Active
- Southeast: Active
- Southwest: Active
- West: Active
OLD WORDING HIDDEN GABE 12-26-2024 - Region Report Form Statuses:
- Midwest: Active
- Northeast: Contacts only. Chapter contacts can be submitted, but the full chapter report form is currently disabled until official release closer to regional conference! Stay tuned.
- Southeast: Active
- Southwest: Active
- West: Active
Region*
I wish to:*

Complete chapter report form AND update chapter contact information.Only update chapter contact Information.
I wish to (update contacts only):*

Only update chapter contact Information.
The information in this form pertains to:*

2024-20252025-2026
Please type the full name of your school*
Please select your regional LMSA Midwest Chapter*
If your chapter is not listed, the chapter may currently be inactive. Please contact cdo.southeast@lmsa.net or director.southeast@lmsa.net.
If you selected "other" for your regional LMSA Midwest Chapter, please write the full name of your school
Please select your regional LMSA Southeast Chapter*
If your chapter is not listed, the chapter may currently be inactive. Please contact cdo.southeast@lmsa.net or director.southeast@lmsa.net.
If you selected "other" for your regional LMSA Southeast Chapter, please write the full name of your school
Please select your regional LMSA Northeast Chapter*
If your chapter is not listed, the chapter may currently be inactive. Please contact cdo.southeast@lmsa.net or director.southeast@lmsa.net.
If you selected "other" for your regional LMSA Northeast Chapter, please write the full name of your school
Please select your regional LMSA West Chapter*
If your chapter is not listed, the chapter may currently be inactive. Please contact chiefinformationofficer@lmsa.net or northernceo@lmsa.net or southernceo@lmsa.net.
If you selected "other" for your regional LMSA West Chapter, please write the full name of your school
Please select your regional LMSA Southwest Chapter*
If your chapter is not listed, the chapter may currently be inactive. Please contact membership.southwest@lmsa.net or director.southwest@lmsa.net.
If you selected "other" for your regional LMSA Southwest Chapter, please write the full name of your school

Identification
Name of Individual Completing Form*

First NameLast Name
Email*
We will contact you with any questions concerning this submission, but will only contact leaders listed in the following page for LMSA organizational information.
I am a:*

Chapter (Co)PresidentChapter (Co)Vice-PresidentChapter Delegate or Medical Student Representative (MSR)Faculty AdvisorOther

Chapter Contact Information

Please update your most current chapter details and leadership contact information.
Institution*
Please write the full institution name and refrain from using acronyms.
Institution Address*

Street Address

Street Address Line 2

CityState

Zip Code
My Institution is an:*

Allopathic Medical School (MD Program)Osteopathic Medical School (DO Program)Undergraduate InstitutionOther
Chapter Leadership

We understand that officer and delegate titles may vary in accordance to your local by-laws. To the best of your ability please match and identify your chapter leaders with the most appropriate officer title below:
Executive Officers

Please enter contact information for your President (or Co-Presidents) and/or Vice Presidents
Officer 1: Chapter (Co) President Name*

First NameLast Name
Please use school e-mail address.
*
Please enter a valid phone number.
Officer 2: Chapter (Co) President and/or Vice President*

First NameLast Name
Please specify if Co President or Vice President

Co PresidentVice President
Please use school e-mail address.
*
Please enter a valid phone number.
Please use school e-mail address.
Please enter a valid phone number.
If you would like to add more board members, please do so below by including their names, position title, phone number, and school email address separated by a comma.
Chapter Advisors

Please enter your faculty and/or chapter advisors.
Advisor Name*

First NameLast Name
Advisor Title*
i.e. Physician, Dean, Professor, School Administrator, etc.
Advisor Institution Affiliation*
i.e. Hospital name, Medical School's name, etc.
Advisor E-mail *
example@example.com
If you have additional advisors, please list them below.

Chapter Service and Activities (January 1, 2025 - December 31, 2025).

The Latino Medical Student Association exists to unite and empower current and future physicians through service, mentorship, and education to advocate for the improved health of the Hispanic & Latina/o/x community in the United States. Please utilize the following set of prompts to show the ways in which your chapter has engaged with our mission.
LMSA Mission Statement #1

To increase representation, support, and retention of healthcare professionals from backgrounds underrepresented among the medical workforce.
Please number and list chapter activities that have been held to meet mission statement #1. *
i.e. August 31, 2023 - M1 Meet & Greet - Event to kickoff the LMSA academic year and allow LMSA members to meet the new LMSA M1s.
LMSA Mission Statement #2

To increase awareness of critical issues affecting the health of the Hispanic, Latina/o/x, and other marginalized communities.
Please number and list chapter activities that have been held to meet mission statement #2. *
i.e. September 14. 2023 - Zoom Lunch with Dr. John Paul Sánchez - Our chapter hosted a Zoom lunch to learn about the effects of COVID-19 on the Hispanic and/or Latina/o/x population in New Mexico.
LMSA Mission Statement #3

To advocate and increase efforts to reduce disparities in the the United States healthcare system.
Please number and list chapter activities that have been held to meet mission statement #3. *
i.e. May 15, 2023 - Health Screening with the Mexican Consulate - Our chapter held blood pressure and other health screenings in partnership with the Mexican Consulate.
Service Hours
If any of the above events from missions #1-3 included community service activities and initiatives, please identify (1) which activities were service events, (2) the date of those events, (3) the number of cumulative hours for events, and (4) the number of volunteers.
Do you give LMSA National and Regional permission to utilize the above information for the consideration of national or regional awards (i.e. Chapter of the Year, Community Service Awards, etc.)?

YesNo
Please upload any photos, flyers, or documentation of chapter activities that you would like shared with our LMSA community on our social media, website, conference programming, and more!

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Chapter Strategic Plan Submission
The LMSA Chapter Strategic Plan is designed to help chapter leaders effectively plan their activities and programs for the upcoming year.

To begin, please download the provided template for the Strategic Plan. After completing it, submit the document for review. For your reference, an example of a completed plan is available below:

Chapter Strategic Plan Template

EXAMPLE of Chapter Strategic Plan
Please upload your completed Chapter Strategic Plan here.*

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Feedback for LMSA National

LMSA National is dedicated to representing students and chapters from diverse regions. Our commitment is to continuously enhance our organization and offer a collaborative platform where students from LHS+ backgrounds, along with their allies nationwide, can unite for a common cause. Please share any feedback you have to help us keep striving towards our goal.
How can LMSA National better support your chapter?
What programming would you like to see from LMSA National?
Our flagship event, the LMSA National Conference, is held annually during Hispanic Heritage Month. What steps can we take to enhance engagement at our national conferences and further strengthen our community?

This following section(s) of this form includes questions tailored to the standards of your LMSA region and may include some questions similar to those answered for LMSA National.

To ensure your chapter remains active, adherence to both regional and national requirements is necessary.

Click "Next" to proceed.

LMSA Midwest
Officers

In addition to the chapter leaders already reported, LMSA Midwest would like to engage with other officers from your chapter in order to organize and share opportunities pertaining to their role(s). Please list additional officers below, if applicable.
Mentorship Chair

First NameLast Name
Please enter school e-mail address.
First NameLast Name
Service Chair

First NameLast Name
Please enter school e-mail address.
Please enter a valid phone number.
Other Chair Name
Reflections on this Past Year (January 2025 - December 2025)
Of all the work your chapter has completed this past year, what is your chapter most proud of? (150 word max) *
(500 word max)
Of all the work your chapter has completed this year, which initiatives/service events were new versus previously established? (150 word max)*
What was your chapter's greatest challenge this past year? (150 word max) *
(500 word max)
What was your most successful event this past year? (150 word max) *
(500 word max)
Did you have any events that were unsuccessful? What went wrong and could go better next time with your chapter? (150 word max)*
(500 word max)
Did your chapter experience a change in your school’s Diversity, Equity, and Inclusion (DEI) Office this year? What does the DEI Office look like right now? Who do you have support from now (i.e. faculty, administration, etc.)? (150 word max) *
(500 word max)
What is the best way for LMSA Midwest to communicate with your chapter?*
Did your chapter utilize any resources or benefit from any events held by LMSA Midwest this year, such as funding, letters of support, workshops, etc.? Please be specific. (150 word max) *
(500 word max)
Feedback Request for LMSA Midwest Region

In alignment with our commitment to enhancing the quality of work and strengthening our relationships with chapters in the LMSA Midwest region, we invite your feedback on our performance and initiatives during the past year (2025 Calendar Year).
What projects/events/ideas that LMSA Midwest implemented this year worked well? (150 word max) *
(500 word max)
Which areas from the work we did this year should be improved? (150 word max) *
(500 word max)
Are there any ideas or projects you would like the LMSA Midwest to consider/implement? *
(500 word max)
Consideration for LMSA Midwest 2026 Chapter of the Year
The LMSA Midwest Chapter of the Year Award will be awarded to one LMSA Midwest chapter who embodies the LMSA mission and has demonstrated a strong commitment to advancing the health and well-being of Latinx/Hispanic communities.

The following factors will be considered in the selection process:
1. Chapter’s responses in the Annual Chapter Report Form
  - Specifically, questions in the Chapter Service and Activities Section
  - In addition to the additional COTY-specific Questions
2. Attendance at:
  - Co-director Quarterly Meetings
  - Fall 2025 House of Delegates Conference
  - Spring 2025 Midwest Conference
3. Completion of community service event tracking form: Community Service Event Tracker
Please check all of the following that may apply to your chapter in the last three years (January 2023-December 2025)

In the last three years, my chapter was selected for LMSA Midwest Chapter of the YearIn the last three years, my chapter applied for a LMSA Midwest Chapter GrantIn the last three years, my chapter has served as a host for the LMSA Midwest Annual Regional ConferenceIn the last three years, my chapter has served as a host for the House of Delegates/MOLA ConferenceIn the last three years, my chapter hosted events in collaboration with an LMSA+ chapter (or Latinx premedical org)In the last three years, my chapter has helped establish a new LMSA+ Chapter
Please check all of the following that may apply to your chapter in the last year (January 2025-December 2025)

My chapter has had representation on the LMSA Midwest BoardMy chapter has had representation on the LMSA National Board
If your chapter has had representation on the LMSA Midwest/National Board, please indicate how many and whether they served on the Midwest or National team. (i.e. 0 on Midwest, 1 on National)
Please share why your chapter should be selected as this year's Chapter of the Year? We encourage you to reflect on challenges as well as successes. Please be descriptive and use objective measures to add to your rationale (i.e. # of service events, $ raised, mentorship efforts, etc).
(500 word max)
Maintenance of Active Chapter Status
Active Chapter Requirements: To maintain active status, a Local Chapter must:
- Send at least TWO (2) Delegates (or their chosen representative(s)) to each annual LMSA Midwest conference: the House of Delegates (HOD) and the Regional Conference, and the Quarterly Virtual Delegate meetings
  - If extenuating circumstances arise, chapters must submit a request for only ONE (1) delegate to attend. Approval will be at the discretion of the Executive Board
- Submit an annual report per annual deadlines detailing the number of Local Chapter members and listing events conducted by the Local Chapter during the academic year
  - Required events must include a minimum of one service event per chapter report cycle
- Adhere to guidelines given by LMSA Midwest and any subcommittees of the former in order to promote the purposes and objective of the organization
- Avoid misrepresenting or damaging the name and/or reputation of LMSA Midwest or LMSA National
- Chapter delegates must report changes in local chapter leadership within one month directly to the CDO and Co-Directors
- Abide by all LMSA National Chapter Requirements
To maintain active chapter status:

I understand that to maintain active chapter status, the chapter must abide by the requirements listed above.

Northeast
Yearly Update Form
Chapter email:*
example@example.com
In addition to the chapter leaders already reported, LMSA Northeast would like to engage with other officers from your chapter in order to organize and share opportunities pertaining to their role(s). Please list additional officers below, if applicable:
E-board Transition
When was your most recent transition?*

MonthDayYear
Date
When will your next transition take place? (If unsure, estimate month or write TBD)*
Funding
How much estimated funding (in dollars) does your chapter receive?*
If funding varies, please explain the process by which your chapter secures funding through your school:
End of Year Progress Report

This form along with your completed excel spreadsheet will be used to name the Dr. Helen Rodriguez Trias Chapter of the Year. The deadline to submit this form + completed excel spreadsheet is below.
Deadline: Friday, Feb 7th, 2026 at 11:59pm EST
Dr. Helen Rodriguez Trias Chapter of the Year

The award is given to the chapter that best exemplifies the ideals of LMSA-Northeast, namely to recruit Latinos into higher education, educate about Latino health issues, advocate for increased Latino representation in health-related areas, and promote awareness about social, political and economic issues as they relate to Latino health, through its activities throughout the year. The winning medical school chapter will be awarded $600 for travel and 8 tickets to the Gala hosted on March 7th, 2026. during the LMSA-Northeast Regional Conference. If you are selected as the awardee, you will be notified in advance via email in February. We will do a public announcement of the winner at the LMSA-Northeast Regional Conference. If you are designated as the chapter awardee and do not plan to have any members attend the gala, please let us know via email at directorelect.northeast@lmsa. net

Additionally, we will award a LMSA+ Chapter for Chapter of the Year award. The criteria for this award are the same as that for the LMSA Medical Chapter of the year. The LMSA+ chapter that wins this award will receive registration for up to 5 of its members to attend the Northeast Regional Conference!
LMSA Chapter Information
How many members are in your chapter?*
Number of first year students involved in your chapter:*
Number of second year students involved in your chapter:*
Number of third year students involved in your chapter:*
Number of fourth year students involved in your chapter:*
How many members are National dues-paying members?*
Did members of your chapter apply to any of the scholarships offered this year?*

YesNo
Please submit a picture of your Eboard and/or members for the NE website. *

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LMSA NE Feedback
Do you feel that LMSA-NE supported you in reaching your goals this year? Pleaseprovide examples, comments, suggestions, feedback, etc.*
What is one thing you think the LMSA-NE Executive Board did well this year? (or more than one!)*
What would you like to see more of from the LMSA-NE Executive Board? Do you have any suggestions, advice, or feedback for us?*
Chapter Reflections
What are things you think your chapter did well this year?*
What was your chapter’s greatest challenge this past year (2025)?*
What was your most successful event this past year (2025)? Please explain briefly.*
Did you have any events that were unsuccessful? What went wrong, and what could go better next time?*
What are the things you would like more support on?*
Anything else you would like us to know?
Chapter Activities Spreadsheet:

Please download a copy of the spreadsheet template below using your school as the title of the document. Upload the filled template to this form below.

*Please use the honor code system and be truthful about the events listed.*

[Click here to access medical student spreadsheet]

[Click here to access LMSA PLUS student spreadsheet]
Upload Chapter Activities Spreadsheet*

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LMSA West
Chapter Quarterly Report Form
Select the quarter this form submission is for:*

FallWinterSpring
Name of person submitting report:*

First NameLast Name
Position of person submitting report:*
Please use this space to share any chapter updates.
Please use this space to summarize your chapter's events from this quarter, including the name of the event, the date, and approximate number of attendees.
Please use this space to share any upcoming events, including the event dates.
Select if you would like LMSA West to advertise your event on social media:

Yes, I would like for LMSA West to advertise the above upcoming events.
Please upload any event pictures and/or flyers!

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Chapter Board Members
Add Board Members
Please upload any headshots for the board members above (name the file with their names)

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Chapter Advisors
Add Advisors*
Please upload any headshots for the advisors above (name the file with their names)

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LMSA Southwest
Officers

In addition to the chapter leaders already reported, LMSA Southwest would like to engage with other officers from your chapter in order to organize and share opportunities pertaining to their role(s). Please list additional officers below, if applicable.
Mentorship Chair

First NameLast Name
Please enter medical school e-mail address.
First NameLast Name
Service Chair

First NameLast Name
Please enter medical school e-mail address.
Please enter a valid phone number.
Reflections on this Past Year (January 2025 - December 2025)
Of all the work your chapter has completed this past year (2025), what is your chapter most proud of?*
(500 word max)
What was your chapter's greatest challenge this past year (2025)? *
(500 word max)
What was your most successful event this past year (2025)? Please explain briefly. *
(500 word max)
Did you have any events that were unsuccessful? What went wrong, and what could go better next time?*
(500 word max)
Feedback Request for LMSA Southwest Region

In alignment with our commitment to enhancing the quality of work and strengthening our relationships with chapters in the LMSA Southwest region, we invite your feedback on our performance and initiatives during the past year (2025).
What projects/events/ideas that LMSA Southwest implemented last year (2025) worked well? *
(500 word max)
Which areas from the work we did last year (2025) should be improved? *
(500 word max)
Are there any ideas or projects you would like the LMSA Southwest to consider/implement? *
(500 word max)
Maintenance of Active Chapter Status
Active Chapter Requirements: To maintain active status, a Local Chapter must:

a. Send at least one delegate to the:
1. House of Delegates (HOD) *occurs in the fall* AND
2. Southwest Regional Conference *occurs in the spring*
b. Submit an annual report prior to January 31st detailing the number of Local Chapter members and listing events conducted by the Local Chapter during the previous academic year

c. Per the bylaws, chapters must complete one service event per year, and that event should be reported in this form (in the 2025 Chapter Service and Events form)

d. Adhere to guidelines given by LMSA Midwest and any subcommittees of the former in order to promote the purposes and objective of the organization; and

e. Avoid misrepresenting or damaging the name and/or reputation of LMSA Southwest or LMSA National.

f. Failure to Maintain Active Status: Any Active Chapter that fails to meet these criteria in a particular year shall be considered inactive for the entirety of the subsequent year, as described in Bylaws II.4, and must meet the stated additional requirements to become active again, as defined in Bylaws II.5.

Submission

Please conclude your submission by providing your signature below. This act signifies your chapter's commitment to accuracy and integrity in all communications and dealings with LMSA. Thank you for your dedication to maintaining the highest standards of integrity.
Signature*
Should be Empty:

Select Region and Chapter

Identification

Chapter Contact Information

Chapter Leadership

Executive Officers

Chapter Advisors

Chapter General Information

Membership Requirements

Delegates or Medical Student Representative (MSR)

Chapter Service and Activities (January 1, 2025 - December 31, 2025).

LMSA Mission Statement #1

LMSA Mission Statement #2

LMSA Mission Statement #3

Service Hours

Chapter Strategic Plan Submission

Feedback for LMSA National

LMSA Midwest

Officers

Reflections on this Past Year (January 2025 - December 2025)

Feedback Request for LMSA Midwest Region

Consideration for LMSA Midwest 2026 Chapter of the Year

Maintenance of Active Chapter Status

Southeast

Meeting and Participation

Diversity and Goals

Collaboration and Feedback

LMSA Plus Chapter

Additional Information (optional)

Northeast

Yearly Update Form

E-board Transition

Funding

End of Year Progress Report

LMSA Chapter Information

LMSA NE Feedback

Chapter Reflections

LMSA West

Chapter Quarterly Report Form

Chapter Board Members

Chapter Advisors

LMSA Southwest

Officers

Reflections on this Past Year (January 2025 - December 2025)

Feedback Request for LMSA Southwest Region

Maintenance of Active Chapter Status

Submission