Colorado School of Public Health

Concentration/Campus Declaration Form

Please complete the following form and attach an unofficial transcript for the new Concentration Director to review. Please return completed form to the Office of Student Affairs or fax to 303.724.4620. Please note students can change home campus only once during their MPH career. All concentration and campus change requests will be considered on a space-available basis and are not official until they receive final CSPH approval.

Student Name: ______Student ID Number: ______

Current Campus: ______Current Concentration: ______

Please specify intended route of action below:

_____ I am declaring my initial concentration

_____ I am requesting a concentration/focus area change from my original concentration

_____ I am making a campus change from my original campus designation

_____ I am adding a second concentration and pursuing a dual concentration option

_____ I am dropping one of my dual concentrations – please specify which one you are dropping: ______

Please specify intended campus and concentration/focus area(s) below:

1/8/2013 CSPH

_____ Animals, People, and the Environment (CSU)

_____ Applied Biostatistics (AMC)

_____ Community & Behavioral Health (AMC)

_____ Global Public Health Option

_____ Community Health Education (UNC)

_____ Environmental and Occupational Health (AMC)

_____ Global Public Health Option

_____ Epidemiology (please specify campus below)

_____ AMC

_____ CSU

_____ Global Health Option (AMC Only)

_____ Global Health and Health Disparities (CSU)

_____ Health Communication (CSU)

_____ Health Services Research (AMC)

_____ Health Systems Management (AMC)

_____ Health Systems, Management & Policy (AMC)

_____ Global Health Option

_____ Leadership and Public Health – Online (AMC)

_____ Maternal & Child Health (AMC)

_____ Global Health Option

_____ Physical Activity & Healthy Lifestyles (CSU)

_____ Public Health Nutrition (CSU)

1/8/2013 CSPH

Student Signature Date

Concentration/Program Director Signature (concentration you are exiting) Date

Concentration /Program Director Signature (concentration you are entering) Date

______

Dual Concentration/Program Director Signature (if applicable) Date

______

Assistant Dean of Student Affairs Signature Date

Faculty Advisor Assignment: (should be entered by the Concentration Director): ______

1/8/2013 CSPH