Worksheet showing G.P.

A information and Clinical Hours Calculations

Submit a completed copy with your application. Start both tables with the most recent information
Name:
G.P.A Information:

(If needed, please ask a college counselor for assistance in completing this form.)

Semester School System

Quarter School System
College or University
Cumulative
Cumulative
Cumulative
Cumulative
G.P.A.
G.P.A.
Names and dates of
Grade
Grade
Units
Units
attendance
Points
Points
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
Sum Totals
0
0 #DIV/0!
0
0 #DIV/0!
Direct Patient Care (DPC) Contact Hours:
Start Date
(M/D/Y)

Employers

End date
(M/D/Y)

# of
Weeks

# of Hours
Est.'d % of
Worked/We
DPC
ek

DPC
Hours

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
Sum Total
# Hours worked /Week must represent real estimate of the average time worked per week
Est.'d % of DPC Contact (should be a whole number between 0 - 100) = % of time you actually worked with
patients, not including transportation, idle or administrative time
DPC Hours = (# of Weeks) X (# of Hours worked / week ) X (Estimated % of DPC Contact / 100.
Primary Care Associate Program, 1215 Welch Road, Module G, Palo Alto, CA 94305-5408

0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0
0.0

Worksheet showing G.P.A information and Clinical Hours Calculations

EXAMPLE ONLY (use "PCAP worksheet" for your information)

Submit a completed copy with your application. Start both tables with the most recent information
Name: Iman Applicant
G.P.A Information:

(If needed, please ask a college counselor for assistance in completing this form.)

Semester School System

Quarter School System
College or University
Cumulative
Cumulative
Cumulative
Names and dates of
Grade
G.P.A.
Units
Units
attendance
Points
Acorn College (1/11-6/12)
60
226
3.77
Rydell College (7/12-12/12)
20
70
3.50
West University (1/13-3/13)
#DIV/0!
16
East University (4/13-6/13)
#DIV/0!
12
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
Sum Totals
80
296
3.70
28
Direct Patient Care (DPC) Contact Hours:
Start Date
(M/D/Y)

Employers
Superior Hospital
Best Hospital
University Hospital
Northern Hospital
Southern Clinics

1/1/2009
1/1/2010
1/1/2011
1/1/2012
2/1/2013

End date
(M/D/Y)
12/31/2009
12/31/2010
12/31/2011
2/1/2013
7/31/2013

# of
Weeks
52.0
52.0
52.0
56.7
25.7
0.0
0.0
0.0
0.0
0.0
0.0

# of Hours
Worked/We
ek
20.0
20.0
30.0
30.0
30.0

Sum Total

# Hours worked /Week must represent real estimate of the average time worked per week
Est.'d % of DPC Contact (should be a whole number between 0 - 100) = % of time you actually worked with pati
not including transportation, idle or administrative time
DPC Hours = (# of Weeks) X (# of Hours worked / week ) X (Estimated % of DPC Contact / 100.
Primary Care Associate Program, 1215 Welch Road, Module G, Palo Alto, CA 94305-5408

al Hours Calculations

information)
e most recent information

nce in completing this form.)

Quarter School System

Cumulative
Grade
G.P.A.
Points
#DIV/0!
64
40

104

Est.'d % of
DPC
100%
100%
50%
50%
60%

4.00
3.33
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
#DIV/0!
3.71

DPC
Hours
1040.0
1040.0
780.0
850.7
462.9
0.0
0.0
0.0
0.0
0.0
0.0
4173.6

d per week
me you actually worked with patients,

C Contact / 100.