New Certificate Request Form

New Certificate Request Form

For questions regarding program modifications, please contact

Heather Peck (hpeck@osrhe.edu).

NOTE: This form cannot be saved and should be completed in its entirety at one time.

INSTITUTION AND PROGRAM INFORMATION

Institution*

Select or enter value

Certificate Type*

Select or enter value

Official Certificate Title*

Do NOT include the certificate type in this field.

CIP Code (6-digits)*

Will the certificate be embedded?*

Yes

Name of program certificate will be embedded in*

Program code certificate will be embedded in*

Location(s) where certificate will be offered*

Separate each location with a comma.

Requested Instructional Program Code

If left blank, the next available program code will be assigned.

Govering Board Approval Date*

CONTACT INFORMATION

Name of Chief Academic Officer*

Email of Chief Academic Officer*

Are you the Chief Academic Officer*

Yes

Name of person completing this form*

Title of person completing this form*

Email of person completing this form*

PROPOSAL INFORMATION

Certificate Purpose*

In one or two sentences describe the purpose of the proposed certificate.

Total number of hours required for the certificate*

Method of Delivery*

Traditional Only

Electronic Only

Traditional and Electronic

IPEDS INFORMATION

IPEDS has expanded the required reporting information regarding distance education in regards to degree programs and now requires information on three aspects of degree programs based on CIP code and degree level groupings. For more information regarding IPEDS reporting, go to the following website: https://nces.ed.gov/ipeds/use-the-data/distance-education-in-ipeds.

Distance Education Availability*

For the proposed certificate, including general education courses, please select the statement that describes the certificate's distance education availability.

ALL of the courses in the program can be completed entirely online

SOME of the courses in the program can be completed entirely online

NONE of the courses in the program can be completed entirely online

For the proposed program, including general education courses, please select the appropriate response to each of the following statements.

For the purposes of these questions, a mandatory onsite component refers to a course requirement or activity in which a student MUST be physically on campus, such as orientation, laboratory requirements, meeting with faculty and is a part of the student’s overall class performance and grade.

For the purposes of these questions, onsite refers to the physical campus and NOT off-campus locations for internships, practica, clinicals, etc.

This certificate has a mandatory onsite component*

Yes

This cert has a non-mandatory onsite component

Yes

Send me a copy of my responses

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