Demographics

9 digit UT Pin:   Pharmacy Class  Choose one P1 P2 P3 P4 Advanced Standing   Graduating Class of  Choose one Class of 2002 Class of 2003 Class of 2004 Class of 2005 Class of 2006 Class of 2007 Class of 2008 Class of 2009 Class of 2010    

My cumulative G.P.A. (to two decimal places) is       Age Choose one 21 - 25 years 26 - 30 years 31 - 35 years 36 - 40 years > 40 years     Gender   Choose one Male Female      Marital Status  Choose one Single Married Separated Divorced    

Children Choose one None 1 2 3 > 3

Ethnicity (optional, but please choose "Prefer not to divulge" if you wish to not divulge your ethnicity) Choose one Caucasian African American Oriental/Asian Hispanic Other, please specify Prefer not to divulge  
If other ethnicity, please specify

What is the size of your home town?   Choose one < 2,500 2,500 - 5,000 5,000 - 10,000 10,000 - 25,000 25,000 - 50,000 50,000 - 100,000 > 100,000  

What is the size of the community in which you hope to practice? Choose one < 2,500 2,500 - 5,000 5,000 - 10,000 10,000 - 25,000 25,000 - 50,000 50,000 - 100,000 > 100,000

Where do you plan to practice after graduating? Choose one Community pharmacy Independent community pharmacy Hospital pharmacy Government Chain pharmacy Industry Education Undecided Other    If other, please specify : 

Will you complete your Pharm.D. as:  Entry-level Pharm.D. Post-B.S. Pharm.D. Pharm.D./Ph.D.

    If Pharm.D./Ph.D., to which program are you enrolled?  Choose one Health Science Administration - Pharmacoeconomics Health Science Administration - Health Policy Pharmaceutical Sciences - Pharmaceutics Pharmaceutical Sciences - Medicinal Chemistry

Will you apply to a fellowship   residency  upon completing your Pharm.D.?

Do you plan to pursue your education further?    Yes    No 

    If yes, will you apply to (check all that apply):   Continuing Education  Medical School    Law School    MBA 

      Graduate School    Dentistry    Other    If other, please specify: 

Coursework/Degrees Attained

Pre-Pharmacy:

    Name of Institution attended for pre-pharmacy:    Private    Public

    Hours completed     Degree(s)  Attained Associate Bachelor Master Doctorate None

Additional:

    Name of Institution attended:    Private    Public

    Hours completed     Degree(s) Attained Associate Bachelor Master Doctorate None