MPH Service Learning/Capstone Experience Handbook

Form A UNMC Master of Public Health Program Application for Service Learning/Capstone Experience (Incomplete or Unsigned Applications will not be accepted)

Student Name______Capstone Chair______

Concentration Area: ___BIO ___BIO/EPI ___CHE ___COPC ___EPI ___ EOH ___HP ___HPOL ___MCH ___PHA ___PHP ___SMHC

Expected Graduation Date _____/______/_____ Date application submitted_____/______/_____ Semester to start service learning ______

CORE COURSES--List Core Courses and Semester Enrolled/Completed

Courses Semester Enrolled/Completed &Grade CPH 500 Foundations in Public Health ______CPH 506 Biostatistics I / CPH 516 Biostatistical Methods I ______CPH 504 Epidemiology Theory and Applications/ CPH 621 Fundamental of Epidemiology ______CPH 503Public Health, Environment and Society ______

CPH 502 Health Services Administration ______

CPH 501 Health Behavior ______

CPH 505 Applied Research in Public Health/ CPH 517 Design of Medical Studies ______GPA for completed coursework: ______

Core courses completed Yes____ No____ Total credit hours completed ____

CONCENTRATION AREA COURSES--List Concentration Courses and Semester Enrolled/Completed

Courses Semester Enrolled/Completed &Grade ______ELECTIVE COURSES List Courses and Semester Enrolled/Completed

Courses Semester Enrolled/Completed &Grade ______

SL/CE pre-requites have been met Yes____ No____ Total credit hours completed ____

Has a placement site been identified? Yes____ No____ If Yes, Name of Placement Site______**Confirm with SLA that an Affiliation Agreement (Form C) is on file and current. If No, List Area(s) of Interest for Service Learning Experience (contact SLA for help with identifying a site if needed): ______

Location: County: ______

City: ______

______Printed Student Name Student Signature:

______SL/CE Committee Chair Name SL/CE Committee Chair Signature

______Academic Advisor Name Academic Advisor Signature

To be completed by the student and a copy submitted to the Director of the Masters Programs prior to receiving permission numbers to register for CPH 528 and CPH 529.