We are collecting the following information for two purposes: To better match you with a mentor with shared life experiences, and to assess our goals for reaching underrepresented applicants. These data will only be seen by Project SHORT committee members. Aggregate counts and percentages may be released, but we will never share or sell your personally identifying information at any point. You may select "prefer not answer" to any questions you do not wish to answer.
In which country do you currently reside? *
Choose
United States
Canada
Prefer not to answer
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d’Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
The Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
In which state do you currently reside? *
Choose
I do not reside in the United States
Prefer not to answer
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
How Old Are You? *
Choose
Under 21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
Undergraduate university (please include full name, no acronyms) *
Your answer
What is/was your undergraduate major? *
Your answer
PharmD university (please include full name, no acronyms) *
Your answer
What is your current educational status? *
Choose
1st year PharmD
2nd year PharmD
3rd year PharmD
4th year PharmD
What is the highest level of education your parents/guardians completed? *
Some High School
High School
Vocational/Technical Training
Some College
Associate's Degree (Two-year College)
Bachelor's Degree (Four-year College)
Master's
Doctorate
N/A
Prefer not to answer
Parent/Guardian 1
Parent/Guardian 2
Parent/Guardian 3
Parent/Guardian 4
Some High School
High School
Vocational/Technical Training
Some College
Associate's Degree (Two-year College)
Bachelor's Degree (Four-year College)
Master's
Doctorate
N/A
Prefer not to answer
Parent/Guardian 1
Parent/Guardian 2
Parent/Guardian 3
Parent/Guardian 4
For Which Application Cycle Are You Applying? *
Choose
2020 – 2021
2021 – 2022
2022 – 2023
Areas of Interest *
Required
How Well Do You Think Your Experiences Prepared you for This Program? *
How familiar are you with the resources available to help you with your application process (other than Project SHORT)? *
Which services are you interested in receiving? Check all that apply.
Where do you plan to apply? Check all that apply. *
Required
Do you identify as any of the following? (Please check all that apply – but do not feel obligated to disclose anything you are not comfortable sharing.) *
Required
What race/ethnicity(ies) do you identify with? Check all that apply. *
Required
What is your gender? *
Do you have any physical or mental disabilities? *
Required
How would you define your family of origin's class? *
Choose
Upper class
Upper-middle class
Middle class
Lower-middle class
Poor or near poor
Prefer not to answer
How would you define your current class? *
Choose
Upper class
Upper-middle class
Middle class
Lower-middle class
Poor or near poor
Prefer not to answer
One of the goals of Project SHORT is to mentor and support applicants of diverse experiences and backgrounds. How do you as an individual contribute to diversity in STEM? (4-5 sentences) *
Your answer
Project SHORT aims to combat socioeconomic and systemic inequalities in medical and graduate school admissions. What barriers do you face in applying to medical/graduate school? *
Your answer
Please provide any other relevant information you believe may help us match you (e.g. undergraduate institution, socioeconomic background, career goals, etc).
Your answer
How did you hear about us (check all that apply)? *
Required
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