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 disqualified.

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.)

Biographical QuestionnaireFor Applicants to the Faculty of Health Sciences

• ALL HEALTH SCIENCES APPLICANTS are required to complete the Biographical Questionnaire.

•ApplicationswithouttheBiographicalQuestionnairewillbeconsideredincompleteandwillberejected.

• Applicants toOccupational Therapyarealso required to submitaCertificateofAttendanceavailable from theStudentEnrolmentCentre(SEnC),011717-1030,andalsofromthewebsite:

www.wits.ac.za/prospective/undergraduate/application.forms.htm

• Applications for undergraduate admission and Biographical Questionnairesmust reach the Student EnrolmentCentre(SEnC)by30 June 2013. No late submissions will be entertained under any circumstances.

• YouareencouragedtocompleteandsubmitthisBiographicalQuestionnaireonline: www.wits.ac.za/prospective/undergraduate

Surname First name(s) as they appear in your ID document

Person number / student number (if known) Gender

Male Female

Name of school at which you matriculated / will be matriculating from

Matric Authority (e.g. IEB, NSC) 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 BHScOther degrees

at Wits

Please indicate with an X your current position

At schoolTertiary student

Post-school year

Working

SECTION 1: ACHIEVEMENTSThis 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 President Vice-President Executive member Ordinary member

School prefect Head Prefect Deputy Head Prefect Prefect Other:

Junior city counsellor Formal Mentor / Tutor School / Peer Counselor Monitor / Class Representative

“People to People” Scouts /Guides Cadets Golden Key

Other leadership roles:

Awards (indicate with an X or list accordingly)

President’s award Bronze Silver Gold Other awards:

Honours blazer/Colours Half Full

Page 2

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

Club/Society/Activity (examples are listed below)

Specify the name or type of club/society/activity (if none write N/A)

Pres

iden

t

Vic

e-Pr

esid

ent

Exec

uti

ve

Mem

ber

Co

mm

itte

e M

emb

er

Ord

inar

y M

emb

er

Soci

al /

Sc

ho

ol

Un

iver

sity

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 newspaperName of newspaper:

editor deputy editor journalistother:

TheatreName of production:

director producer actor

Musical Instrument Instrument level 1 level 2 level 3

First Aid level 1 level 2 level 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)

Sport (if none, please indicate N/A)

Cap

tain

Vic

e-C

apta

in

Team

M

emb

er

Soci

al /

C

lub

Sch

oo

l

Un

iver

sity

Pro

vin

cial

Nat

ion

al

Athletics /cross country / running / shot put/ discus /high/long jump / track and field

Basketall / Netball / Softball / Baseball / Netball

Cricket / Indoor cricket

Football / Soccer / Indoor soccer

Golf / Volleyball

Hockey (field 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:

SECTION 1: ACHIEVEMENTS (CONTINUED)PLEASE USE AN X TO ANSWER ALL OF THE SECTIONS BELOW. WRITE N/A IF NO ACTIVITY IS RECORDED.

What do you do in your free time?

1. 2. 3. 4.

Name three (3) personality traits which are, according to you:

your best 1. 2. 3.

your worst 1. 2. 3.

SECTION 2: LANGUAGESPlease circle the language(s) you speak OTHER than English. Indicate with an X the level of fluency you are able to communicate in with [1] indicating a basic knowledge (few words) to [4] being able to read, write and communicate fluently.

Languages[1]

(few words)[2] [3]

[4]

(Fluent)

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):

A. Social engagement (non-medical voluntary)

Name of organisation

Specify your dutiesNumber of hours undertaken since June 2012

Please supply the name and contact details of an individual (supervisor/other) who may be contacted to confirm your duites and the hours worked. False information would result in the application being disqualified.

Name

Position

Address of organisation

TelephoneOffice Cell no. Email

B. Exposure to the health sciences profession

Name of organisation

Specify your dutiesNumber 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 confirm your duites and the hours worked. False information would result in the application being disqualified.

Name

Position

Address of organisation

TelephoneOffice Cell No. Email:

SECTION 3: SOCIAL ENGAGEMENT AND HEALTH SCIENCES EXPOSURE

Page 3

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

SECTION 4: SCHOOL AND HOME ENVIRONMENT

Page 4

Specify the area where your school is situated

Suburb Township Rural

Indicate the type of school you attended

Private School (non-boarding)

Private School (boarding)

Public School (non-boarding)

Public School (boarding) Home School

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

Less than 5km

Less than 10km

Less than 15km

More than 15km

How you travel to and from school/university? Private car Motorbike/Scooter Bicycle Walk/Bus Taxi/Train

What time do you leave home for school/university in the mornings?

Before 5:30 a.m.

Between 5:30 & 6:00

Between 6:00 & 6:30

Between 6:30 & 7:00

Between 7:00 & 7:30

For which of the following do you use a computer and the internet?

school work / projects / assignments research for school / university Email

downloading music / movies facebook / twitter / youtube / mxit /other

Do you have access to the following at home?

Computer Yes No Internet access Yes No Electricity Yes No

Provide the name and contact details of an individual who has agreed to act as a referee and who may be contacted to confirm the information you have supplied as TRUE and an honest reflection 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)