Learning Experience Approval Form

Learning Experience Approval Form

Please complete the Learning Experience Approval form below. Your proposal will be carefully reviewed by the Health Policy Certificate staff, and you will receive notice as soon as possible about your experience approval. In some cases, more information may be requested of you.

This form is also used to apply for retroactive approval of an experience.

Last Name*

First Name*

Email*

Introductory Course*

Have you completed the Introductory Course PUBPOL 165?

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What best describes the status of your learning experience?

Please choose from the dropdown.

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How many hours will this experience fulfil?

Please select one.

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Type of Experience

Please select experience from the drop-down menu or select Other and explain below.

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Other Experience

Please write in what type of experience you would like to undertake.

Supervisor Name

Supervisor Email

Start*

End*

Please provide a description of the entire project.*

We HIGHLY RECOMMEND that you fill the following sections out WITH your (future) supervisor, unless you have completed the experience already. Please address the following questions: What will you be investigating during your learning experience? How is the activity related to US health policy? What do you hope to learn (theoretical knowledge, practical skills, abilities)? What specific US health policy topic will your experience address? What will be your work setting? With which health policy-related communities, organizations, or individuals do you expect to interact? (250 words maximum, can be bullet points).

Please describe your (anticipated) role(s) and responsibilities.

What deliverables from this experience will you be posting on your e-Portfolio?*

This should be something that best captures the work you do for the experience (for example: poster(s), paper(s), interview(s), TED-talk(s) and the like).

Will you receive course credits and/or a grade for this experience?

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Location of Experience

Send me a copy of my responses

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