Dear MPH Student:

Before you submit this form, please make sure that your Capstone advisor has already approved your project.  When you submit this form, your Capstone advisor will automatically receive an email message from the MPH office acknowledging his\her approval of your project.

Thank you.  MPH Program Office

MPH CAPSTONE INFORMATION FORM

(Fields marked with are required.) First Name Last Name Email Address Capstone Project Title Provide a brief description of the specific aims of your project Capstone Advisor's Name (lastname, firstname) Capstone Advisor's Email Address (for approval) Faculty Academic Advisor's Name (lastname, firstname) Faculty Academic Advisor's Email Address Capstone Project Type Choose One Primary Data Analysis Secondary Data Analysis Literature Review Program Evaluation Program Proposal Policy Analysis Research Proposal Other Other (If you selected "Other" above, please describe project type.) Was your capstone conducted for, requested by, or in collaboration with an organization other than Johns Hopkins? Yes No If Yes, please answer the following. Name and Location of Organization: City and State: Country: Preceptor's or Supervisor's Name: Preceptor's or Supervisor's Phone Number: Preceptor's or Supervisor's Email Address. Are you enrolled in an official concentration area? Yes No If Yes, which concentration? (Please select one.) Go to next question if you are not enrolled in a formal concentration area. Choose one Child & Adolescent Health Epidemiologic & Biostatistical Methods Global Environmental Sustainability & Health Health in Crisis and Humanitarian Assistance Health Leadership & Management Health Systems & Policy Infectious Diseases Nutrition, Food, and Health Social & Behavioral Sciences Women's & Reproductive Health If you are Customizing your program of study - To help guide us in scheduling the presentation sessions, please check the most appropriate broad topic area for your capstone project. Choose One Child Health Clinical Epidemiology Investigations Environmental/Occupational Health Health Policy & Management HIV/AIDS Humanitarian Assistance Infectious Diseases Injury Prevention International Health Mental Health Nutrition Social & Behavioral Sciences Women's & Reproductive Health Other Other (If you selected "Other" above, please indicate topic area.) Does your capstone involve the collection of and/or analysis of data from people? Yes No If Yes, does your project have IRB approval? Yes No If Yes, indicate type of approval. Choose one New JHU protocol Existing JHU protocol Protocol at another institution If No, indicate status of proposal. Choose one Submitted to IRB Plan to submit to IRB Oral Presentation. How will you complete your oral presentation requirement? Online (for part-time/Internet-based students): August 12, 2013 Online (for part-time/Internet-based students): December 10 & 11, 2012 Online (for part-time/Internet-based students): May 6, 7 & 8, 2013 Saturday, May 11, 2013 Alternative Venue If you are presenting in the May Online sessions, please indicate if you have a preference in date. Monday, May 6, 2013 Tuesday, May 7, 2013 Wednesday, May 8, 2013 No Preference Alternative Venue. List venue, date, and location.

If you experience any problems with this form, please email webadmin@jhsph.edu