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 OnePrimary Data AnalysisSecondary Data AnalysisLiterature ReviewProgram EvaluationProgram ProposalPolicy AnalysisResearch ProposalOther 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 oneChild & Adolescent HealthEpidemiologic & Biostatistical MethodsGlobal Environmental Sustainability & HealthHealth in Crisis and Humanitarian AssistanceHealth Leadership & ManagementHealth Systems & PolicyInfectious DiseasesNutrition, Food, and HealthSocial & Behavioral SciencesWomen'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 OneChild HealthClinical Epidemiology InvestigationsEnvironmental/Occupational HealthHealth Policy & ManagementHIV/AIDSHumanitarian AssistanceInfectious DiseasesInjury PreventionInternational HealthMental HealthNutritionSocial & Behavioral SciencesWomen's & Reproductive HealthOther 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 oneNew JHU protocolExisting JHU protocolProtocol at another institution If No, indicate status of proposal. Choose oneSubmitted to IRBPlan to submit to IRB Oral Presentation. How will you complete your oral presentation requirement? Online (for part-time/Internet-based students): August 8, 2011 Online (for part-time/Internet-based students): December 5, 2011 Online (for part-time/Internet-based students): May 7, 8 & 9, 2012 Saturday, May 12, 2012 Alternative Venue If you are presenting in the May Online sessions, please indicate if you have a preference in date. Monday, May 7, 2012 Tuesday, May 8, 2012 Wednesday, May 9, 2012 No Preference Alternative Venue. List venue, date, and location.

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