FORM J

CERTIFICATE OR LICENSURE PROGRAM PROPOSAL

Department:
Contact Person:
Email: / Phone:
Date:

Please use bold for responses and place (X) where appropriate.

1. Program Title:
2. Degree program that certificate is derived from:
3. Required Credit Hours: ___
4. Level:
( ) PB Post-Baccalaureate Certificate
( ) PM Post-Master’s Certificate
( ) LP Licensure Program (post-baccalaureate)
5. 6-digit CIP Code: / Specialty Code: / 000
(If you know the specialty code, then please replace "000" with the correct value. Otherwise, please leave "000" as the default value.) Approved CIP Codes for UNCG can be found on the UNC-GA Degree Finder
6. Certificate Program only: Do you plan to pursue and comply with Gainful Employment regulations for student financial aid eligibility? http://www.ifap.ed.gov/GainfulEmploymentInfo/indexV2.html
( ) Yes ( ) No
7. Requested Start Term:
8. Rationale for Offering Program: Provide a complete explanation for the requested change. Additionally, please include rationale for program length/ number of credit hours, including references to external professional standards, accreditation requirements, etc., if applicable.
9. Student Learning Objectives (SLOs), including rationale:
10. For Whom Planned:
11. Admission Requirements: (Provide an explanation if no admissions test is required.):
12. Program Requirements:
13. Bulletin Text:
14. The proposed certificate or licensure program is a:
( ) brand new program
( ) new mode of delivery that is offered in addition to an existing program
( ) new mode of delivery that replaces an existing program
If replacing, how will students enrolled (current, incoming, and 2+ if applicable) be allowed to complete their course of study?
15. Mode of Delivery (Place an (X) for all applicable modes of delivery):
( ) on campus
( ) 100% online Delivered: ( ) synchronous ( ) asynchronous ( ) both
( ) Hybrid % of program online:_ %_ Delivered: ( ) synchronous ( ) asynchronous ( ) both
( ) off-campus (include complete street address):__
16. Consultation with other departments (Attach Form B: Course/Program Consultations)
17. Attach the completed Signature Sheet for Form J (see next page).

SIGNATURE SHEET

CERTIFICATE OR LICENSURE PROGRAM PROPOSAL

Requests will not be considered without the appropriate signatures.

Department:
Program Title:
Contact Person:

Please Sign and Print Name in the Following Order

1
Dean of Academic Unit / Date
2
Chair, Department Curriculum Committee (if applicable) or Department Head / Date
3
Chair, Academic Unit (College/School Curriculum Committee) / Date
4
Associate Dean for Academic Affairs and Student Services in the School of Education
(If applicable for teacher licensure) / Date
Approval by UCC and/or GSC
The requested action has been approved through UNCG’s internal curricular processes.
This change is found to be within the scope of the mission of The University of North Carolina at Greensboro.
DATE APPROVED / Chair, Graduate Studies Committee
DATE APPROVED / Chair, Undergraduate Curriculum Committee

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