Interdisciplinary Certificate in Health Disparities

Applicant Information Sheet

All fields with a red star are required. If the field is not applicable to you, just type 'n/a' in the field.

If you have any problems or questions filling out this form, please contact:
The Program on Ethnicity, Culture, and Health Outcomes
Phone: (919) 843-3539
Fax: (919) 966-7457
send us a message

First Name

  Middle Initial

  Last Name

   
Address

City

  State

  Zip

   
Work Phone

  Home Phone

  Cell Phone

   
Email Address


Education:
College/University

  City/State

  Degree Awarded

  Date
MM/DD/YYYY
     
     

Current Professional Position and/or Graduate Program:

   
Department Registrar's name and telephone number:

  Academic Advisor (if applicable):

Graduate Program Start/Enrollment Semester:

  Expected Graduation Date: MM/DD/YYYYY

SUBSTANTIVE AREA:


Please describe your past and current research experience(s):


Please describe your past work (volunteer or paid) experience(s) in the area of health disparities:


Please describe what you hope to gain from completing the certificate:


If you are not a University of North Carolina at Chapel Hill student you must first obtain an application from the Division of Continuing Education at the Friday Center (919-962-1134).  After completing the application, you will need to contact each Department in which a course is being offered to register for courses.

University of North Carolina at Chapel Hill students interested in the Interdisciplinary Certificate in Health Disparities will follow the regular course registration process. However, some courses require course Department approval before enrolling in a course.

ALL PARTICIPANTS will need to advise their home Department that they are enrolled in the Interdisciplinary Certificate in Health Disparities Program.

Primary Graduate Program Course Plan (Please list all of the required courses for your graduate program):

Course Number/Title Semester Week Day and Time

Proposed Certificate Program Course Plan (List all the courses you anticipate completing to fulfill the health disparities certificate. Please refer to the listing of approved certificate program courses.):

Course Number/Title Semester Date Completed
MM/DD/YYYY
MHCH/EPID 892 Interdisciplinary Seminar in Health Disparities
MHCH756/PUBH756 Understanding and Addressing Health Inequalities in the US