Culture, Health, and Science Certificate Checklist
Student Name as you would like it to appear on your certificate: __________________________________
School: ____________________________
Student ID Number: __________________ Year of Graduation: ____________ Fall
Spring Summer
Email Address (after graduation): ______________________
Address to Send Certificate:
(Certificates my be sent after
graduation)
Certificate Requirements (Check when completed) :
◻ Student has taken a minimum of 7 courses from the approved certificate course list
◻ No more than 4 courses used to satisfy CHS requirements also fulfill major requirements
◻ Student has taken at least one course from each of the 5 categories below
◻ At least 4 courses used to satisfy CHS requirements were above introductory level
◻ No course has been used to satisfy more than one category
◻ Student has received a grade of “B” or better in all courses counting toward the certificate
◻Student has attached an unofficial copy of their transcript of courses and grades
◻ Project Requirement: Student has completed a thesis, Division III project, course project, independent research
project, or internship that has been pre-approved by their campus advisor
◻Population Level: Suggested but not required: At least one course has exposed the student to mechanisms of
disease transmission at the level of the population (*P)
◻ Language Skills: Suggested but not required: Student has taken (check one) 1 ◻ 2 ◻ 3 ◻ 4 ◻ semesters of
foreign language
Required Independent Research Project (check one) :
Internship ◻ Thesis ◻ Division III Project ◻ Course Project ◻ Independent Study ◻ Other ◻
Objective of project/internship:
Internship location:
Date of Internship:
Description of Final Product:
Approval of Campus Advisor
Date
Courses:
Category I: Biocultural Approaches
Intro
Upper
College Department
Course Number and Title
Grade
*P
◻
◻
1.______________________________________________________
◻
◻
◻
2.______________________________________________________
◻
◻
◻
3.______________________________________________________
◻
Category II: Mechanism of Disease Transmission
Intro
Upper
College Department
Course Number and Title
Grade
*P
◻
◻
1.______________________________________________________
◻
◻
◻
2.______________________________________________________
◻
◻
◻
3.______________________________________________________
◻
Category III: Population, Health and Disease
Intro
Upper
College Department
Grade
*P
◻
◻
1.______________________________________________________
◻
◻
◻
2.______________________________________________________
◻
◻
◻
3.______________________________________________________
◻
Category IV: Ethics, Policy and Practice
Intro
Upper
College Department
Course Number and Title
Course Number and Title
Grade
*P
◻
◻
1.______________________________________________________
◻
◻
◻
2.______________________________________________________
◻
◻
◻
3.______________________________________________________
◻
Category V: Research Design and Analysis
Intro
Upper
College Department
Course Number and Title
Grade
*P
◻
◻
1.______________________________________________________
◻
◻
◻
2.______________________________________________________
◻
◻
◻
3.______________________________________________________
◻
Optional Comments:
Completion of requirements:______________________has satisfactorially completed the requirements of the
Culture, Health, and Science Certificate.
When you have completed the requirements, or in the last semester of your senior year, please submit the
completed form along with a copy of your transcript to your CHS campus advisor.
Signature of campus CHS program advisor
Date