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Medical Student Performance Evaluation

In order to have a Medical Student Performance Evaluation (MSPE) prepared and sent please complete the following information. All information submitted will be verified and any student falsifying information will not be eligible for a MSPE.

  1. Student's first name (legal):
    last name:

  2. Email:
    NSU email address ONLY e.g. username@nova.edu
  3. Gender: Male Female

  4. Undergrad School:

  5. Degree earned:

  6. Please provide a brief summary (600 characters or less) of any distinguishing characteristics, significant challenges or hardships encountered during medical school. You should use the third party when writing the brief summary (he/she or first name). "Click here for example"



  7. Date of expected graduation: mm yy

  8. Date of matriculation: mm yy

  9. Did you take any leave(s) of absence while you were in Medical School:
    yes no

  10. If yes to #9, please select:

  11. Did you transfer to NSU: yes no

  12. If transfer student:
    Date of initial matriculation in prior medical school:
    mm dd yy

    Date of transfer from Prior medical school:
    >mm dd yy

    School   

  13. Did you enroll in dual/joint/combined degree: yes no

  14. If dual/joint/combined degree:
    Date of initial matriculation with other degree program:
    mm yy

     Date of expected graduation from other degree program:
    mm yy

    Type of other Degree Program:

  15. Did you repeat any coursework during your medical education yes no

  16. If you repeated coursework, please select:


  17. While in medical school, did you recieve any disciplinary actions
    yes no

  18. If yes to question #14, please select


  19. Class rank: out of a class of

  20. Grade point average: %

  21. Please list school - related activities that you have been a participant:
    (DO NOT use abbreviations for student organizations (I.e. SOMA), or other activities, use full name of organization or activity.) Use COMAS to separate each school or activitie.



Revised: October 5, 2004