Third Year Medical Student Professional Responsibility Form

BUSM III Students will need to complete the form by Monday, May 2, 2022. Please review ALL the policies listed on BUSM III Policies for Clinical Rotations prior to completing form below.

Third-Year Required Orientation Form

Criminal Background Policy, Medical Student Responsibilities

"*" indicates required fields

Last Name*

First Name*

Email*

Today's Date*

Medical Student Professional Responsibility Agreement*

I have read and reviewed the policies posted on BUSM’s Policies webpage . Policies are subject to change at any time. I will review all policies on an annual basis.

Title IX Policies and Resources*

I have read and reviewed the Sexual Misconduct/Title IX Policy posted on the BUSM Policies webpage.

Criminal Record Information Disclosure Agreement*

Yes

Have you been convicted of a felony or misdemeanor in the United States or internationally since you completed your application to medical school, or since you last completed this form at a prior orientation?

Criminal Record Information Notification Agreement*

Yes

N/A

If you answered yes to the above question, have you notified the Associate Dean of Student Affairs, Angela Jackson, of any felony or misdemeanor conviction against you in the United States or internationally?

Criminal Record Information Notification Agreement*

Do you agree to notify the Associate Dean of Student Affairs should you be convicted of a felony or misdemeanor while enrolled at BU Chobanian & Avedisian School of Medicine?

BUSM Policies

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