EDUCATION, TRAINING AND RESEARCH SERVICES

Medical Training Division

EVALUATION FORM FOR INCOMING HOUSE STAFF

I. PERSONAL INFORMATION

Name: , M.D. Date of Birth:

Last Name Given Name M.I. (month / date / year)

Address:
PRC Number: E-mail:
Contact Numbers: (landline ) CP #
Person to be notified in case of emergency:

II. TRAINING BAC KGROUND

School last attended:
Degree Finished:
PASSED:
Board of Medicine (Y/N) Date: Score:
Specialty Board (Y/N) Date:
POSITION(S) HELD: (check appropriate box)
 Chief Resident  Chief Fellow
 President/Leader Residents/Fellows Association
 Others
(pls specify): ________________________________________

III. AWARDS/HONORS RECEIVED

IV. INTENDED PLACE OF PRACTICE

Metro Manila (pls specify):

Province (pls specify):

V. HEALTH ISSUES (pls. specify)

YES NO
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FM-E-ETD-MTD- 2019- 007

Rev.01