Supplemental Information Form

Part of the application for the Master of Public Health Program

Southern Connecticut State University

Please provide the information requested below to supplement your application for admission to the Master of Public Health program at SCSU. This form is a required part of the application packet. Please remit this completed form to the Graduate School, along with all other required portions of the application. Applications that are missing this document will be considered incomplete and will not be reviewed until this and all other required elements of the file have been received by the Graduate School.

Applicant Information:

First Name: / Last Name:
Email: / Date of Birth:

Section 1: Summary of Education

Please list all higher education received, starting with the most recent. If a degree is still in process, please indicate the expected completion date. If a degree was not completed, please write “NC” in the last column.

Degree / Major / Institution / Date Completed

Section 2: Professional and Volunteer Experience

Both paid and volunteer work experience in Public Health is a valuable asset for MPH applicants. Please describe up to 4 years of work experience in the space provided below. If you have more than 4 years of work experience, emphasize your public health work below. If you do not have experience in public health, emphasize what you feel is most relevant. Do not write “see resume.”

Job Title: / Paid or Unpaid?
# of Months Employed: / Full or Part Time?
Employer:
Duties:
Job Title: / Paid or Unpaid?
# of Months Employed: / Full or Part Time?
Employer:
Duties:
Job Title: / Paid or Unpaid?
# of Months Employed: / Full or Part Time?
Employer:
Duties:
Job Title: / Paid or Unpaid?
# of Months Employed: / Full or Part Time?
Employer:
Duties:

Section 3: Awards and Publications

List below any awards you have received and/or publications you have contributed to during or after your undergraduate work. Attach additional sheets as needed.

Date / Name and Description / Organization

Section 4: Foreign Languages

Please list any foreign languages that you know and indicate your degree of fluency.

Language / Fluency

Section 5: Leadership Experience

Please list below your leadership experience after high school. This can include leadership roles in charitable, social, or professional groups, paid or unpaid supervisory experience, community initiatives or any other experience that requires leadership skills.

Role and Description / Organization / # of Months