Fourth Year Medical Student Professional Responsibility & Criminal Record Information Disclosure Agreement Fourth Year Medical Student Professional Responsibility & Criminal Record Information Disclosure Agreement Form, 2025-26 Academic Year Name* First Last BU Email* Class Year* Date* MM slash DD slash YYYY Criminal Record DisclosuresCriminal Record Information Disclosure Agreement*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? Yes No Criminal Record Notification Agreement*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? Yes No N/A Criminal Record 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 School of Medicine? Yes Annual Student Disclosures & Policy ReviewMedical Student Professional Responsibility & Code of Conduct Agreement* I have read and reviewed the policies (linked here) . Policies are subject to change at any time. I will review all policies on an annual basis. Medical Student Code of ConductPolicy on Evaluation, Grading and Promotion of Students (SEPC)* I have reviewed and attest to following the Policy on Policy on Evaluation, Grading and Promotion of Students. I will review this policy annually. Policy on Evaluation, Grading and Promotion of StudentsTitle IX Policy and Resources* I have read and reviewed the Sexual Misconduct/Title IX Policy. I will review this policy annually. Title IX Policy and ResourcesPolicy on the Appropriate Treatment in Medicine* I have reviewed and attest to following the Policy on the Appropriate Treatment in Medicine (ATM). I will review this policy annually. Policy on the Appropriate Treatment in Medicine (ATM)Technical Standards* I have reviewed and attest that I am equipped to follow the Technical Standards. I will review this policy annually. Technical StandardsNameThis field is for validation purposes and should be left unchanged.