Keio University
Graduate School of Health Management
Personal History (Doctral Program)

D1
Examination*no need to fill out

NumberName：
Academic and employment background (list your academic record from entrance into highschool and employment history starting with the oldest experience)(Note) As far as possible, clarify the respective faculty, department, graduate school, and major, etc., for youracademic record, and the section/department, position, and occupation type for your employment history.
Periodfromto( year / month ～ year / month )/～//～//～//～//～//～//～//～//～//～//～//～//～//～//～//

～//

～/

Details(faculty,department,major/organization,section, position, occupationtype)Research experience (bachelorʼs thesis, masterʼs thesis, publications, conference presentations, etc

健マ研 2025

D2
Name：

Examination
Number*no need to fill out

Qualifications and licenses

Rewards and punishments

Affiliated groups (societies, research groups, athletic associations, NPOs, other)

Other items for special mention (including publications and conference presentations, etc.)

健マ研 2025

Keio University Graduate School of Health Management
Aspirations and Motivations (Doctral Program)
Name：

D3
Examination*no need to fill out

NumberBased on your research activities, work experience, and social engagement (including extracurricularand student club activities while at university and graduate school) up until now, describe youraspirations and motivations for admission, competencies based on your perceived strengths, points for
improvement post-admission, and career plan after completing the doctoral program (approx. 800-1200
characters in Japanese, 400-700 words in English).

(Note) The screening results will be invalidated if it is recognized that the Personal History, Aspirations and Motivations
for Applying, Research Plan was plagiarized or composed by a third party.
健マ研 2025

D4

Keio University Graduate School of Health Management
Research Plan (Doctral Program)
Name：

Examination*no need to fill out

NumberDescribe your proposed research post-admission (problem awareness, research plan for the three yearsof enrollment, significance of research, etc.; approx. 800‒1200 characters in Japanese, 400-700 words
in English).

(Note) The screening results will be invalidated if it is recognized that the Personal History, Aspirations and Motivations
for Applying, Research Plan was plagiarized or composed by a third party.
健マ研 2025

D52025 年度
慶應義塾大学大学院健康マネジメント研究科後期博士課程《志願者に関する所見・評価書》Applicant Evaluation Form
Doctoral Program
Graduate School of Health Management
Keio University〈評価者の方へ〉 To the Evaluator
下記の志願者について，率直かつ正確な所見をご記入ください。記入後は，任意の封筒に厳封のうえ，志願者にお渡しください。
Please give an accurate evaluation of the academic performance and aptitude of the following applicant.
Please seal this form in an envelope, sign across the seal, and then give it back to the applicant.
【志願者氏名】Applicantʼs name年月yearmonthdate日記入

不明【志願者の教育研究者としての素質に関する評価】（該当するところに ○ 印をつけてください）
Please rate the ability of the applicant as a researcher/educator by circling the applicable items.

①

研究実績

特に優れている

優れている

Excellent

Good

普通劣

Fairる

非常に劣る

Poor

Very Poor

Cannot Evaluate

Research achievement②

研究者としての潜在能力

Potential as a researcher③

教育者としての潜在能力

Potential as an educator④

研究管理・実施能力

Ability to manage and implement research⑤

創造性・独創性

Creativity and originality

◎

総合評価

強く推薦する

推薦する

どちらともいえない

推薦しない

Strongly recommended

Recommended

No Opinion

Not recommended

不明

Cannot Evaluate

Overall assessment【志望者に関する所見】 Comments on the applicant※この枠内に納まらない場合は別紙を添付してください。*If you require additional space, please attach a separate sheet.

所属 Affiliation, Position/Title

記入者氏名 Evaluatorʼs name in full (please print)㊞
Signature

連絡先 Address〒−

Telephone number（志願者との関係 Relationship to the applicant

1． 研究指導教員 Academic advisor
2． その他 Other（please specify:）−）Email address
健マ研 2025