Notification of Certificate Completion
Instructions: This form must be completed and submitted to the certificate’s administrative contact after
the final grades for all certificate courses have been posted in ISIS. The certificate cannot be granted or
included in the transcript until the form is submitted and verified by the certificate program.
This 2-page form is a writeable pdf file. It is preferable to complete the form electronically, however the
form can be printed and the information legibly written. Send the completed form to the certificate’s
administrative contact as an email attachment or via the postal system. A paper certificate of completion
(suitable for framing) will be mailed 4-8 weeks after this form is submitted. Email the certificate’s
administrative contact if the certificate is not received within 8 weeks.
Certificate name _____________________________________________________________
Student’s name as it should appear on the certificate of completion
___________________________ ___________________
First
Middle
__________________________
Last
Student’s email that will be active for at least 3 months ______________________________
Postal address exactly as it should appear on the package
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
For reaccreditation, the School is required to report aggregate employment information.
Check (X) which best describes you currently. (check all applicable) I am
___ Enrolled in a degree program
___ A post-doctoral fellow
___ A (medical/surgery) resident or fellow
___ Seeking employment
___ Not employed by choice
___ Employed (other than post-doc or resident/fellow) in a health-related area
___ Employed (other than post-doc or resident/fellow) in a non health-related area
1 Notification of Certificate Completion
Student’s name ______________________________________________________________
List each certificate course completed. Alternatively, provide a photocopy of your transcript
with the certificate courses highlighted.
Required courses
Course #
Course Name
Please explain all course waivers or substitutions (or other pertinent information).
2012.08.06
2