3. Conflict of interest and commitment: (check-off as many as appropriate)
Complete the following courses with 3.00 or better grade: (course number/title)
___________________________________________________________________
Satisfactorily complete the following CITI modules (discipline, module name)
___________________________________________________________________
Receive other training (type of training, provider, form of assessment)
___________________________________________________________________
___________________________________________________________________
4. Ethical issues in data acquisition, management, sharing and ownership: (check-off as
many as appropriate)
Complete the following courses with 3.00 or better grade: (course number/title)
___________________________________________________________________
Satisfactorily complete the following CITI modules (discipline, module name)
___________________________________________________________________
Receive other training (type of training, provider, form of assessment)
___________________________________________________________________
___________________________________________________________________
Submitted by: (must be the Graduate Coordinator or Department Chair)
(signature) __________________________________________________ (date) __________
(name) _____________________________________________________
Graduate School Approval: (Dean or Associate Dean)
(signature) __________________________________________________ (date) __________
Copy: Department, Degree Audit