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Student Acknowledgement Form


The Tennessee Public Health Workforce Development Consortium offers multi-institution, on-line graduate certificates in Public Health.  This consortium provides students with high quality, coordinated instruction from experts at several universities.  After formal admission to their home institution, students will also enroll in the Tennessee Public Health Workforce Development Consortium’s certificate programs directly.  Credits earned within these certificate programs are counted at the home institution as regular, not transfer, credit.

As a Tennessee Public Health Workforce Development Consortium participant, you have selected the university that you wish to have as a “home institution” by applying for admission to that school.

To register a student in a class the home university enters student specific information into the “Consortium” database.  The information entered into the database will include the student’s home institution, social security number, name, address, telephone number, e-mail address, course registration, and other relevant data.  This allows the teaching university immediate access to class lists and provides the university with necessary student activity reports.  Software and data will be stored and maintained on a secure central database server.  A limited number of university staff or faculty will be granted access to the database on a need-to-know basis.


 

Student Acknowledgement Form Submission

I understand will be disclosing my personal identifiable information in the manner outlined above.  I understand the purpose of sharing this information within the Tennessee Public Health Workforce Development Consortium's multi-institutional program.  * required field

Last Name*       

First Name*      

Middle Name

SS Number*      

Email Address*

Date of Submission:*