Master of Science in Medical Science (MSMS) Program

PRE-APPLICATION FORM

Each pre-application for admission cycle starts on September 1 and ends on March 30. Please note that submitting the pre-application form is a separate process from applying for admission to the program. It is required that you complete this pre-application first. Also, note that this program is ONLY for educationally and/or economically disadvantaged students during the time they grew up, not in their current status.

The Summary Sheet and Legal Disclosure Forms must also be completed when submitting a pre-application. Thoroughly complete both forms, save them, attach them to an email and send to msms@iupui.edu. Your Pre-Application will be on HOLD until these forms are received. Click here for Summary Sheet and Legal Disclosure Forms.

Personal Information

Name*

Phone

Best time to contact you

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

State of Legal Residency*

Gender*

Female
Male

Date of Birth*

Ethnic Background*

Citizenship Status*

US Citizen
Permanent Resident

Please explain how the MSMS Program would be suitable for you. Also, tell us what you've been doing since graduating.

Have you applied to IUSM before?*

Yes
No

Are you planning to apply to IUSM from the MSMS Program?*

Yes
No

How did you hear about the MSMS Program?*

Academic Information

MCAT Scores

1st Attempt Date

Chemical and Physical Foundations of Biological Systems

Critical Analysis and Reasoning Skills

Biological and Biochemical Foundations of Living Systems

Psychological, Social, and Biological Foundations of Behavior

Total

2nd Attempt Date

Chemical and Physical Foundations of Biological Systems

Critical Analysis and Reasoning Skills

Biological and Biochemical Foundations of Living Systems

Psychological, Social, and Biological Foundations of Behavior

Total

3rd Attempt Date

Chemical and Physical Foundations of Biological Systems

Critical Analysis and Reasoning Skills

Biological and Biochemical Foundations of Living Systems

Psychological, Social, and Biological Foundations of Behavior

Total

Premedical Science Requirements

Please check all requirements that have been completed.

Biology 1

Lecture
Lab

Biology 2

Lecture
Lab

General Chemistry 1

Lecture
Lab

General Chemistry 2

Lecture
Lab

Organic Chemistry 1

Lecture
Lab

Organic Chemistry 2

Lecture
Lab

Physics 1

Lecture
Lab

Physics 2

Lecture
Lab

Overall undergraduate GPA Calculation: For each course: Grade Weight x Credit Hours = Quality Points
Total Quality Points:________ ÷ Total Hours: ________= Overall undergraduate GPA: ________

Science* GPA Calculation: Total Science Quality Points: ________ ÷ Total Science Hours: ________=
Overall Science GPA: ________

*Science = Biology, Chemistry, Physics, and Math

Freshman Hours

Freshman GPA

Sophomore Hours

Sophomore GPA

Junior Hours

Junior GPA

Senior Hours

Senior GPA

Post-Baccalaureate Hours

Post-Baccalaureate GPA

Graduate Hours

Graduate GPA

Undergraduate Institution(s)

Undergraduate Major

Undergraduate Minor

Overall Undergraduate GPA

Science GPA (i.e.: Biology, Chemistry, Physics, Math

Year in college

Bachelors degree completion date

Have been a non-degree seeking post baccalaureate student?

Yes
No

Have been a graduate degree seeking student?

Yes
No

Have you had an academic dismissal or withdrawn from any academic program including medical programs?

Yes
No

If yes, complete the following four fields:

Institution attended and reason for leaving

Major

GPA

Medical School Application Dates:

1st Attempt

2nd Attempt

3rd Attempt

Disadvantaged Student Status

Are you educationally disadvantaged?

Applicant is considered "educationally disadvantaged" if he/she "comes from an environment that has inhibited the individual from obtaining the knowledge, skills, and abilities required to enroll in and graduate from a undergraduate college or health professions school.

Yes
No

The term "educationally disadvantaged" refers to both educational and social disadvantage
%%(1) Such as coming from a low-income family
%%(2) Limited English proficiency families (English as a second language)
%%(3) The individual graduated from (or last attended) a high school that was on probation and/or received low per capita funding (Per student expenditure)
%%(4) The individual graduated from (or last attended) a high school/middle/elementary at which, he/she was eligible for free or reduced price lunches
%%(5) The individual comes from a family that received public assistance (e.g., Aid to families with dependent children, food stamps, Medicaid, public housing)

If yes to educationally disadvantaged, please describe the pre-college (Kindergarten through 12th grade High School) conditions that put your school and students attending at a disadvantage.

If yes to educationally disadvantaged, please supply school district, county, the name, address and phone number of your K through 12 Schools.

Are you economically disadvantaged?

Yes
No

If you checked yes the following site will allow you to confirm your economically disadvantaged status. This table will allow you to compare your 2015 earnings to the amount you are allowed under economically disadvantaged.

Family income levels are employed to evaluate economic disadvantage.

Reference from http://msms.iu.edu/admissions/eligibility "Family Income Levels"

Please check all that apply:

Are you claimed as a dependent by either or both parents on their most recent federal tax return?

Yes
No

Record the amount of family taxable income (if claimed as a dependent) or your personal taxable income, reported to the IRS for the most recent tax year.

Joint Return

Number of family members

Individual Return

Father

Number of family members

Mother

Number of family members

Personal (only)

Would you provide copies of income tax information if you are invited to submit an MSMS Program application for admission?

Yes
No

I was eligible for free/reduced lunch in:

Please check all that apply:

Elementary School
Middle School
High School

Please indicate which parent(s) have NOT attained a 4-year college degree - include parents who have some college academic credits or an associate degree.

Mother
Father

Please briefly describe the health disparity issues of your community. Briefly describe your past involvement in that community and potential role as a physician in meeting the health disparity challenges of your community?

Have you reviewed this completed electronic form for accuracy? Have you completed and attached the Summary Sheet and Legal Disclosure forms?*

Yes
No