Name: prefix first name middle name last name suffix. International Telephone: - Personal

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1 HMS/HSDM REUNION REPORT QUESTIONNAIRE SUBMISSION DEADLINE: JANUARY 18, 2017 All information will be printed as entered. Please print legibly and proof your entry. Save time and ensure accuracy by submitting online at PERSONAL INFORMATION: Name: prefix first name middle name last name suffix Nickname: Society: For alumni in classes 1984 to present HMS Degree: Year: HSDM Degree: Year: Date of Birth (mm/dd/year): Gender: CONTACT INFORMATION: Home Address: Use as my preferred mailing address Street: City: State: Zip Code: Country or Territory: Home Telephone: - OR (area code) (number) International Telephone: - (country code) (number) Personal Use as my preferred Business Use as my preferred Other than your post.harvard address 1 P a g e

2 Seasonal Address: If applicable Dates From: To: Street: City: State: Zip Code: Country or Territory: Seasonal Telephone: - OR (area code) (number) International Telephone: - (country code) (number) PROFESSIONAL INFORMATION: Job Status: (circle one) full time, part time, self-employed, semi-retired, retired, temporary/term, unemployed, other : If retired, skip to Briefly describe your research area(s) of interest on page 3 Work Address: Use as my preferred mailing address Title: Employer: Office Address: City: State: Zip Code: Country or Territory: Business Telephone: - OR (area code) (number) International Telephone: - (country code) (number) 2 P a g e

3 Briefly describe your current research and/or health-related area(s) of interest: Please separate interests by semi-colon List your current professional appointments, memberships, and activities: Please list in the following format: Title, Organization; Title, Organization; List your current civic, community, and volunteer activities: Please separate activities by semi-colon FAMILY: Marital Status: (circle one) single, married, committed partner, separated, divorced, widowed Spouse/Partner: first name middle name last name Gender: Is he/she a Harvard/HMS/HSDM alumna/us? (circle one) Yes No Spouse/Partner Job Status: Title: Employer: 3 P a g e

4 Children: What are your children doing? Grandchildren: first name last name year of birth first name last name year of birth first name last name year of birth List additional grandchildren on a separate sheet Harvard Graduate Harvard Graduate Harvard Graduate What are your grandchildren doing? PHOTOS: You may submit up to two photos to be included in your Reunion Report. For best reproduction, please choose photos that are sharp, in focus, well framed, and with good exposure and contrast. You can submit either color or black and white images. If you used a digital camera bought within the last two or three years, your images should be fine. If you are scanning photos, scan them at 100% with resolution set at 300 dpi. In all cases, photos should be at least 600 x 600 pixels. Photo Submission: There are two ways you may submit your photo(s): Send your photo(s) electronically as an attachment to hmsalum@hms.harvard.edu with your name, class year and caption(s) noted Include your printed photo(s) with this questionnaire. Please label the backside of each photo as #1 and #2. Please note: printed photos will not be returned 4 P a g e

5 Photo Captions: Briefly identify the people or setting in less than 20 words in the space below or via the address above. Photo #1: Photo #2: ESSAY: Preferred format for essay submission is a typed document Use the essay to update your story since the last time you wrote. Share your reflections on the past, the present, and the future with your classmates. The section will begin with Dear Classmates: You may continue your essay on an additional sheet 5 P a g e

6 THANK YOU FOR YOUR PARTICIPATION VOLUNTARY PAYMENT: To defray the cost of this publication, we are asking for a voluntary payment of $55. Please make your check payable to Harvard Medical School. I have included a voluntary payment of $55 TO SUBMIT YOUR REPORT: By Mail: By Reunion Report Office of Alumni Relations Harvard Medical School 401 Park Drive, Suite 22 West Boston, MA hmsalum@hms.harvard.edu By Fax: If you have any questions, please call Emma Hastings at P a g e