Qualtrics Survey | Qualtrics Experience Management

Last Name

First Name

Phone #

Primary Email Address

Mailing Address

Name of Medical School

Anticipated date of graduation

I am applying to internal medicine residency during the 2024-2025 cycle?

Yes
No

Are you an International Medical Graduate?

No
Yes

If you have overcome adversity or are from a disadvantaged background*, please describe (200 words max)

*1. Individuals who come from a family with an annual income below established low-income thresholds. These thresholds are based on family size; published by the U.S. Bureau of the Census; adjusted annually for changes in the Consumer Price Index; and adjusted by the Secretary for use in all health professions programs. The Secretary periodically publishes these income levels at http://aspe.hhs.gov/poverty/index.shtml.

For individuals from low income backgrounds, the institution must be able to demonstrate that such participants have qualified for Federal disadvantaged assistance or they have received any of the following student loans: Health Professions Student Loans (HPSL), Loans for Disadvantaged Student Program, or they have received scholarships from the U.S. Department of Health and Human Services under the Scholarship for Individuals with Exceptional Financial Need.

2. Individuals who come from a social, cultural, or educational environment such as that found in certain rural or inner-city environments that have demonstrably and recently directly inhibited the individual from obtaining the knowledge, skills, and abilities necessary to develop and participate in a research career.

Please describe your interest in internal medicine residency and applying to our Gateway to Residency Program? (Max: 500 words)

Please upload your CV

Faculty Letter of Support has been sent directly from the faculty mentor to Alicia Coleman (coleman.a@wustl.edu).

Yes
No

By signing this application, you are agreeing to participate in the program on August 23rd (if selected). You are stating that you understand that participation in this program does not guarantee an interview with the Washington University in St. Louis Internal Medicine Residency Program.

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IDEAS @ DOM (Inclusion, Diversity, Equity, Allyship and Social Justice)
For questions please contact: Alicia Coleman | coleman.a@wustl.edu
Administrative Coordinator for Cassandra Fritz, MD, MPHS