Optional Background Questions

In 1993, the federal government began requiring that any graduate medical education program applying for federal grant support provide data on how many of its applicants, program enrollees and graduates came from a disadvantaged background or medically underserved community. Since the Providence St. Peter Hospital Family Practice Residency Program receives such funding, your response to the following questions would be appreciated. The results of this questionnaire will only be used for the purpose of fulfilling the federal reporting requirement. It will be kept separate from your application and will not be used as part of the selection process.

1. Do you consider yourself to be from a "medically underserved community"? (In most cases, a medically underserved community is a federally defined Health Manpower Shortage Area.)

• Yes | No | If unsure, please list where you are from, including your county.

2. Did you come from an environment that has inhibited you from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a health professions school?

• Yes | No | If yes, please explain:

3. Did you come from a family with an annual income below a level based on low-income thresholds according to family size, published by the U.S. Bureau of the Census, and adjusted annually for changes in the Consumer Price Index, and the Secretary for use in health professions programs?

• Yes | No

Date of report: / / /

Print out and return form to:

Providence St. Peter Hospital Family Practice Residency Program