MEDICAL SCHOLARSHIP AND RETURN SERVICE PROGRAM EVALUATION SHEET
Date Evaluated:__________________
Name of Applicant:
Address: _______________________________________________________________
Name of HEI: College of Medicine, University of the Philippines Manila Course and Year Level:___________
SUMMARY
SCORING:
Qualified: 50 and above Not Qualified:
below 50
Category Weight Score
Category 1: Assessment 10
Category 2: Residency
2a: Geographically Islated and Disadvantaged Areas (GIDA), calamity-prone and conflict areas
20
2b: Certificate of Ancestral of Domain Title (CADT) Area / Indigenous Community
10
2c: Municipality Class/City 10
Category 3: Income (Annual Gross Income) 5
Category 4: Affiliation 5
Category 5: National Medical Admission Test (NMAT) 20
Category 6: General Weighted Average (GWA) 20
Total 100
CATEGORY 1: ASSESSMENT
Criteria Weight Score
Interview / Exam 10
No Interview / Exam 0
Total
CATEGORY 2: ASSESSMENT
Category 2a: Geographically Isolated and Disadvantaged Areas (GIDA)
Criteria Weight Score
GIDA Barangay 20
Municipality with GIDA Barangay 10
Non-GIDA 0
Total Barangay and Municipality:
Category 2b: Certificate of Ancestral Domain Title (CADT) Area / Indigenous Community
Criteria Weight Score
CADT Area/Indigenous Community 10
Non-CADT Area/Non-Indigenous Community 0 Total
CADT Area/Indigenous Community:
Category 2c: Municipality Class/City
Criteria Weight Score
Sixth (6th) Class 5
Fifth (5th) Class 4
Fourth (4th) Class 3
Third (3rd) Class 2
Second (2nd) Class 1
First (1st) Class 0
City 0
Total
Municipality/City (please attach accompanying proof):
CATEGORY 3: INCOME (COMBINED ANNUAL GROSS FAMILY INCOME)
Criteria Weight Score
>Php800,001.00 0
Php450,001.00-800,000.00 1
Php350,001.00-450,000.00 2
Php300,001.00-350,000.00 3
Php250,001.00-300,000.00 4
<Php250,000.00 5 Total
(please attach accompanying proof)
CATEGORY 4: AFFILIATION
Criteria Weight Score
Member of Indigenous People or Minority Group (e.g. Manobo, Aeta, Mangyan, Tausug, Maranao, Badjao, etc)
5
Dependent of Community Health Volunteer 5
Victim of Calamities/Insurgencies 5
Whose Parents are suffering from Chronic Disease(e.g Undergoing Dialysis, CA patients / PWD / Solo Parent)
5
Total Details of Affiliation:
CATEGORY 5: NATIONAL MEDICAL ADMISSION TEST (NMAT)
Criteria Weight Score
NMAT Score 100
Divided by 100 100
Multiplied by 10 20
Total
NMAT Score (please attach accompanying proof):
CATEGORY 6: GENERAL WEIGHTED AVERAGE (GWA)
Criteria Weight Score
GWA Score 100
Divided by 100 100
Multiplied by 10 20
Total GWA (please attach accompanying proof):
RECOMMENDATIONS:
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Evaluated by: Noted by:
MA. LIZA ANTOINETTE M.
GONZALES, MD, MSc CHARLOTTE M. CHIONG, MD, PhD Associate Dean for Faculty &
Students
Dean
