Five College Culture, Health, and Science Certificate Checklist

Students are encouraged to use this form to consult with their certificate advisor, plan for both which courses to take and for completing all certificate requirements. Students are expected to finalize this form with their certificate advisor and attach a copy of their unofficial transcript during the final semester of their senior year: no later than November1stfor fall/January graduates, and April 1stfor spring/May graduates.
More information about program requirements can be found at

Student Name (as it would appear on the certificate):
/ Institution:
Student ID number: / Expected date of graduation (month and year):
Campus Email:
/ CHS Campus Advisor Name (print):
Permanent Email (best way to contact you after graduation):
/ Major:
Phone:
Permanent Address (certificate is mailed to the address provided, normally in July following the date of graduation):

Certificate Requirements(Check when completed):

Student has taken a minimum of 7 courses from the approved certificate course list

For students beginning their studies at a Five College institution in Fall 2015 or after, no more than 3 courses may be used to satisfy CHS requirements as well as to fulfill major requirements. (Students beginning their studies at a Five College institution prior to Fall 2015 may use up to 4 courses to satisfy CHS requirements as well as major requirements.)

Student has taken at least one course from each of the 5 categories below

At least 4 courses used to satisfy CHS requirements were above introductory level

No course has been used to satisfy more than one category

Student has received a grade of “B” or better in all courses counting toward the certificate

Student has attached an unofficial copy of their transcript of courses and grades

Project Requirement: Student has completed a thesis, Division III project, course project, independent research project, or internship that has been pre-approved by their campus advisor

Population Level: Suggested but not required: At least one course has exposed the student to mechanisms of disease transmission at the level of the population. ___Yes ___No. If yes, provide the institution, course number and course title:_______

 Language Skills: Suggested but not required: Student has taken (check one) ___1___2 ___3 ___4 semesters of
foreign language.
To be completed by the advisor:
The aforementioned student has completed all of the certificate requirements. I recommend to the Five College Culture Health and Science Certificate Committee that this student be awarded the certificate.
Advisor Signature: ______ Date Submitted to Committee: ______
The CHSCommittee reviewed this form on this date ______and agreed to award the certificate: ___Yes ___No
Courses:

Intro Level / Upper Level / Institution / Course Title / Department / Course # / Grade B or better (Y/N) / Final Grade Pending (Y/N) / Course Pending CHS Petition Approval* (Y/N)
Category I: Biocultural Approaches
Category II: Mechanism of Disease Transmission
Category III: Population, Health and Disease
Category IV: Ethics, Policy and Practice
Category V: Research Design and Analysis

*To make a request to fulfill a CHS Certificate requirement with a course not included on the Ever Approved Course List ( request approval from your advisor or submit a Course Petition form (available at at least 3 months in advance of graduation.

Advisor Notes Regarding Courses:

Required Independent Research Project (circle one) :

Internship◻ Thesis◻ Division III Project◻ Course Project◻ Independent Study◻ Other◻

Objective(s):

Location and/or organization:

Date(s):

Briefly describe the final product.

Reflection Statement:

Please describe how the unique course of study you have followed to complete the CHS requirements has influenced your understanding of the interconnections between culture, health, and science. Reflect on courses, project work, and any other learning experiences that you have engaged with in pursuing the certificate. (Suggested length: 1-2 pages double spaced.)

Instructions to the program advisor for submitting certificate completion documents:

  1. Meet with student to review requirements and ensure form is completed accurately. Verify that minimum grade requirement has been met (indicate with “yes” or “no”). Clearly mark any courses for which the grade is pending (in progress at the time the documents are submitted). Any in progress grades can be verified after the documents are submitted for processing.
    Note: In order to protect the student’s privacy, please do not include specific grades on this form. Do not email student’s grades ortranscripts (official or unofficial), as electronic communications are not considered sufficiently secure.
  2. Sign and date the form to indicate the advisor’s recommendation of this student for the certificate award.
  3. Submit the form with a copy of the student’s unofficial transcriptto the Five College program Committee or Council overseeing the certificate for final review.
  4. If the Five College program Committee or Council agrees to award the certificate to the student, the documents should be submitted to the Five College staff liaison for final processing by December 15 for fall graduates, and byApril 30 for spring graduates. Please remove the student’s transcript (official or unofficial) before submitting this form to Five College staff (to protect student’s privacy).
  5. The certificate award will be noted on the student’s transcript by the registrar at the student’s institution. A hard copy of the certificate is normally printed and mailed to the student from Five Colleges, Inc. byJuly 15 following the student’s date of graduation.