Postgraduate Department – Initial Assessment & Action Plan Form

Postgraduate Department – Initial Assessment & Action Plan Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
City/State
Year of Education
Visa Status
Are you currently working or volunteering in medical field? (Research/Clinical/Observership/Externship)
Have you completed any USMLE Steps? If so, which steps?
Intended Specialty?
Prior Residency in any other country?
English Level

BeginnerIntermediateUpper-intermediateAdvance
Briefly describe your short term goals (6-9 months)
INITIAL PLAN OF ACTION
This section should be filled out by the department representative after the meeting with the participant.
Assigned Departments

MentorshipUSMLE Step 1USMLE Step 2Local BranchNew comerScholarship
Evaluation of the Candidate’s CV (by interviewer)
First Action Steps

1)2)3)Other
Follow-Up Plan
Assigned Mentor (if applicable):
Should be Empty: