For Applicants to the Faculty of Health Sciences

Biographical Questionnaire
 ALL HEALTH SCIENCES APPLICANTS are required to complete the Biographical Questionnaire. Applications without the Biographical Questionnaire will be considered incomplete and will be rejected.  Applicants to Occupational Therapy are also required to submit a Certificate of Attendance available from the Student Enrolment Centre (SEnC), 011 717-1030, and also from the website: www.wits.ac.za/prospective/undergraduate/application.forms.htm  Applications for undergraduate admission and Biographical Questionnaires must reach the Student Enrolment Centre (SEnC) by 30 June 2013. No late submissions will be entertained under any circumstances.  You are encouraged to complete and submit this Biographical Questionnaire online: www.wits.ac.za/prospective/undergraduate Surname Person number / student number (if known) Name of school at which you matriculated / will be matriculating from First name(s) as they appear in your ID document Gender Male Matric Authority (e.g. IEB, NSC) Female Year

University applicants please indicate current University and degree

Please indicate with an X which programme you are applying for

GEMP MBBCH BDS BScOT BScPhysio BPharm BNurs DipOH BHSc Other degrees at Wits

Please indicate with an X your current position

At school

Tertiary student

Post-school year

Working

This questionnaire provides us with an indication of your well-roundedness, leadership and communication skills, in addition to your ability to balance outside interests with academic demands. Therefore, not all scoring is positive; and false or exaggerated information could lead to your application being disqualied. Please read pages carefully to ensure that the correct information is entered. THIS QUESTIONNAIRE CONSISTS OF FOUR (4) SECTIONS AND EACH OF THESE IS OF EQUAL IMPORTANCE; ALL QUESTIONS ARE COMPULSORY AND MUST BE ANSWERED. (Write N/A if no activity is recorded.)

SECTION 1: ACHIEVEMENTS
This section refers to School / Post-School / University activities. Please mark roles / tasks / descriptions that applied to you over the past two years.
Leadership (Please indicate with an X the position you hold / held. If none, please write N/A.) RCL/SRC School prefect Junior city counsellor People to People Other leadership roles: Awards (indicate with an X or list accordingly) Presidents award Honours blazer/Colours Bronze Half Silver Full Gold Other awards: President Head Prefect Formal Mentor / Tutor Scouts /Guides Vice-President Deputy Head Prefect School / Peer Counselor Cadets Executive member Prefect Golden Key Ordinary member Other:

Monitor / Class Representative

SECTION 1: ACHIEVEMENTS (CONTINUED)

PLEASE USE AN X TO ANSWER ALL OF THE SECTIONS BELOW. WRITE N/A IF NO ACTIVITY IS RECORDED.
Membership of clubs/societies (excluding sports) e.g. chess club, choir member, playing a musical instrument, or any other club belonged to while at high school or University. PLEASE INDICATE POSITION HELD AND WHETHER UNDERTAKEN AT SCHOOL / SOCIAL OR UNIVERSITY LEVEL Committee Member Social / School other: actor level 3 level 3 Provincial Specify the name or type of club/society/activity (if none write N/A) University National Executive Member President VicePresident Ordinary Member University

Club/Society/Activity (examples are listed below)

Chess / scrabble / other Cultural activities (dance / music) Debating / public speaking Environmental group Fitness / gym / spinning / aerobics / weight-training Horse riding / equestrian activities Interact Language club Martial arts / yoga Other: (list) Club / school / university newspaper Theatre Musical Instrument First Aid What do you do in your free time? 1. 2. 3. 4. Name of newspaper: Name of production: Instrument level 1 editor deputy editor journalist

director level 1 level 2

producer level 2

Name three (3) personality traits which are, according to you: your best your worst 1. 1. 2. 2. 3. 3.

Circle the sports you play regularly and indicate with an X in the appropriate column the highest level achieved (e.g. social, school, national) Team Member Captain ViceCaptain Social / Club School

Sport (if none, please indicate N/A) Athletics /cross country / running / shot put/ discus /high/ long jump / track and eld Basketall / Netball / Softball / Baseball / Netball Cricket / Indoor cricket Football / Soccer / Indoor soccer Golf / Volleyball Hockey (eld or ice hockey) Rugby / Touch Rugby Swimming / Diving / Water Polo / Rowing / Canoeing / Other Water Sports Tennis / Table Tennis Other: (list) Evidence of Provincial / National selection and name of team:

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SECTION 2: LANGUAGES
Please circle the language(s) you speak OTHER than English. Indicate with an X the level of uency you are able to communicate in with [1] indicating a basic knowledge (few words) to [4] being able to read, write and communicate uently. Languages 1. Afrikaans 2. English 3. French/German/Greek/Portuguese/Spanish 4. Guajarati /Hindi / Tamil 5. Hebrew / Arabic 6. Kiswahili 7. Xhosa / Zulu 8. Mandarin / Cantonese 9. Sesotho / Sesotho sa Leboa 10. siSwati 11. Tshivenda 12. Tswana 13. Other (list): [1] (few words) [2] [3] [4] (Fluent)

SECTION 3: SOCIAL ENGAGEMENT AND HEALTH SCIENCES EXPOSURE

A. Social engagement (non-medical voluntary) Name of organisation Specify your duties Number of hours undertaken since June 2012

Please supply the name and contact details of an individual (supervisor/other) who may be contacted to conrm your duites and the hours worked. False information would result in the application being disqualied. Name Position Address of organisation Telephone Ofce Cell no. Email

B. Exposure to the health sciences profession Name of organisation Specify your duties Number of hours undertaken since June 2012

Please supply the name and contact details of an individual (supervisor/other responsible person in authority) who may be contacted to conrm your duites and the hours worked. False information would result in the application being disqualied. Name Position Address of organisation Telephone Ofce Cell No. Email:

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SECTION 4: SCHOOL AND HOME ENVIRONMENT

Specify the area where your school is situated Suburb Indicate the type of school you attended Private School (non-boarding) Private School (boarding) Public School (non-boarding) Public School (boarding) Home School Township Rural

Facilities available at your school and used by you on a regular basis Electricity and Running Water Library and Computers Science Laboratories School Hall Playing Fields/ Sports Facilites

How far do you live from school/university?

Less than 2km Private car Before 5:30 a.m.

Less than 5km Motorbike/ Scooter Between 5:30 & 6:00

Less than 10km Bicycle Between 6:00 & 6:30

Less than 15km Walk/Bus Between 6:30 & 7:00

More than 15km Taxi/Train Between 7:00 & 7:30

How you travel to and from school/university? What time do you leave home for school/university in the mornings?

For which of the following do you use a computer and the internet? school work / projects / assignments downloading music / movies Do you have access to the following at home? Computer Yes No Internet access Yes No Electricity Yes No research for school / university facebook / twitter / youtube / mxit /other Email

Provide the name and contact details of an individual who has agreed to act as a referee and who may be contacted to conrm the information you have supplied as TRUE and an honest reection of your activities and circumstances. Referees cannot be family members, colleagues or friends but may be teachers /educators, guidance counselors, ministers or individuals in a position of authority.
Name of referee (full name and title) Position / Designation

Address

Email

Cell no.

Telephone (work)

Fax

Telephone (home)

Please note: The closing date will be strictly adhered to and applications received even one day after the closing date will not be accepted. No late applications will be considered under any circumstances. Queries should be addressed to: Student Enrolment Centre (SEnC), University of the Witwatersrand, Private Bag 4, Wits 2050 Tel: (011) 717 1030 / Fax: (011) 717 1299 / Email: Admission.Senc@wits.ac.za / www.wits.ac.za/prospective/undergraduate

CLOSING DATE FOR APPLICATIONS: 30 JUNE 2013

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