Public Health Leader Certificate Application: Name of Supervisor

1. Online Form

Details about the Public Health Leader Certificate can be found at http://www.biosci.utexas.edu/healthit/informatics.asp

IMPORTANT DUE DATES:

FRIDAY, MAY 25, 5 PM:
Submit the name of your supervisor through this form.

MONDAY, JUNE 11, 8 AM:
Submit the online application.

INSTRUCTIONS FOR COMPLETING THIS FORM

STEP 1:
Fill out your contact and demographic information below.

STEP 2:
Fill in the information about your supervisor. Go to the end of the form and press the "Submit" button. Supervisors will be provided with an online form to submit their letters of recommendation electronically.

For technical questions, contact Dr. Diane Kneeland, dkneeland@austin.utexas.edu

For program questions, contact Dr. Leanne Field, field@mail.utexas.edu

1. Please provide your contact information:

Please provide your contact information: Last Name
First Name
Middle Initial
E-mail
Phone
Cell Phone
Permanent Address

2. LETTER OF RECOMMENDATION
Your supervisor will be contacted by email to provide an evaluation. The recommendation must be received before June 1 at 5pm.

LETTER OF RECOMMENDATION Your supervisor will be contacted by email to provide an evaluation. The recommendation must be received before June 1 at 5pm. Title
Organization
Email
Phone Number

3. Additional or Second Supervisor Reference (OPTIONAL)

Additional or Second Supervisor Reference (OPTIONAL) Title
Organization
Email
Phone Number