Once submitted you will be contacted through the e-mail you listed in Section 1 - Personal Data. Please contact Josué Martinez at Josué.Martinez@utah.edu or 801-587-7896 with questions. What type of Certificate? Check one: Certificate in Global Health Certificate in Public Health Certificate in Emergency Health Certificate in Statistics Public Health/Biostatistics Track Are you considered a resident by the University of Utah? (If not sure, please call the Residency office at 801-581-8761): Yes No Term and Year applying (Choose only one) Fall: Spring: Summer: SECTION 1 - PERSONAL DATA First Name: * Last Name: * Middle Initial: University ID (if applicable): Home Address: * City: * State: * Zip: * Phone Number: Email Address: * SECTION 2 - ACADEMIC BACKGROUND Undergraduate Degree: Undergraduate Major: University: Graduation Semester & Year: GPA: Graduate or Current Degree (if applicable): University: Graduation Date (DD/MM/YY): GPA: SECTION 3 - GLOBAL HEALTH CERTIFICATE APPLICANTS ONLY List the semesters and year you plan on taking each core course: PBHLT 6530 Global Health (Semester & Year): PBHLT 6531 International Fieldwork (Semester & Year): PBHLT 6502 International Public Health Issues (Semester & Year): List the semesters and years you plan on taking each approved elective: 1. Elective: Semester & Year: 2. Elective Semester & Year: Planned Certificate completion date (Semester & Year): SECTION 3 - PUBLIC HEALTH CERTIFICATE APPLICANTS ONLY List the semesters and year you plan on taking each core course: PBHLT 6100 Biostatistics I (Semester & Year): PBHLT 6300 Epidemiology I (Semester & Year): PBHLT 6400 Public Health Management & Practice (Semester & Year): PBHLT 6600 Social and Behavioral Science in Public Health (Semester & Year): PBHLT 6700 Environmental & Biological Science in Public Health (Semester & Year): Planned Certificate completion date (Semester & Year): SECTION 3 - EMERGENCY HEALTH CERTIFICATE APPLICANTS ONLY List the semesters and year you plan on taking each core course: PBHLT 6780 Emergency Public Health: Planning for Disasters (Semester & Year): PBHLT 6781 Post-Disaster Community Health (Semester & Year): PBHLT 6340 Infectious Disease Epidemiology (Semester & Year): PBHLT 6980 Emergency Health Practicum (Semester & Year): PBHLT 6960 *Public Health Practicum (in lieu of Emergency Health Practicum for MPH students (Semester & Year): List the semesters and years you plan on taking each approved elective: 1. Elective: Semester & Year: 2. Elective: Semester & Year: Planned Certificate completion date (Semester & Year): SECTION 3 - PUBLIC HEALTH STATISTICS CERTIFICATE APPLICANTS ONLY Please list the Pre-Requisites you have completed in order to take the below Public Health/Biostatistics Courses #1 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #2 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #3 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #4 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #5 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #6 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #7 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #8 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #9 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): #10 Pre-Requisite (Course Name/Number, Grade, Year Taken, Institution): List the semester and year you plan to take the Public Health / Biostatistics Courses (Please select 9 Credit hours from the following) PBHLT 6106 - Categorical Data Analysis (3 Credit hours) (Semester & Year): PBHLT 7115 - Causal Methods in Public Health (3 Credit Hours) (Semester & Year): PBHLT 6300 - Epidemiology I (3 Credit hours) (Semester & Year): PBHLT 7100 - Biostatistics II (3 Credit hours) (Semester & Year): PBHLT 7120 - Linear and Logistic Reg. Models (3 Credit hours) (Semester & Year): PBHLT 7130 - Longitudinal Data Analysis (3 Credit hours) (Semester & Year): PBHLT 7300 - Epidemiology II (3 Credit hours) (Semester & Year): This should be noted, “Classes may not be offered every year. Applicants will need to verify with Laura Egbert (laura.egbert@utah.edu), prior to making their selections”. Please select 6 Credit hours from the following: STAT 6003 - Survey of Statistical Computer Packages (3 Credit hours) STAT 6769 - Introduction to Hierarchical Linear Models (3 Credit hours) STAT 6969 - Spec Topic in Statistics (3 Credit hours) STAT 6571 - Found. Of Applied Data Analysis & Visualization (3 Credit hours) STAT 6572 - Nonparametric Statistics (3 Credit hours) STAT 6573 - Practical Data Science (3 Credit hours) STAT 6574 - Intro to Bayesian Methods (3 Credit hours) SECTION 4 - LETTER OF INTENT Describe why you are interested in this Certificate program (not to exceed 500 words): SECTION 5 - UNOFFICIAL TRANSCRIPTS Please email & attach your unofficial transcripts from every previous institution you have attended to Josué Martinez at josue.martinez@utah.edu Leave this field blank
