Global Health Education Community Information

Community Service Activities Report

To better document the range and extent of community service activities of University of Connecticut medical students, the Office of Community Based Education has established this online recording method. Please provide your best estimate of the number of hours you volunteered for each project in which you participated. In addition, we ask that you indicate any leadership roles you contributed, including serving as manager, board member, in fundraising, etc. The preceptor is the teacher/person you worked with. If you have any questions, please contact Stacey Brown or Judy Lewis in the Community Based Education office.

Thank you.

First name: Last name: Start year of medical school: Year in program:
American School for the Deaf Health Education Program
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Bridge to the Future: Science Mentorship Program
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Community Partners in Action Mentoring and Health Education
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Habitat for Humanity
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Hartford Health Education Program
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

High School Health Professions Recruitment Exposure Program (HPREP)
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Migrant Health Worker Clinic
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Pediatric Scholars Reading Program
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

New Britain YMCA Cardiac Education Project
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

South Marshall Street Clinic
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

South Park Inn Clinic
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Tar Wars
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

YMCA Adolescent Clinic
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Youth Science Enrichment Program (YSEP)
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Other Programs/Agencies
Program/Agency Name:
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Program/Agency Name:
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Program/Agency Name:
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments:

Program/Agency Name:
Dates attended:	Hours:	If leadership role, state type:	Preceptor:
From: To:
Assignments: