UNIVERSITY OF WASHINGTON, Department of Health Services 
EXTENDED MPH DEGREE PROGRAM 
Email:  uwedp2@u.washington.edu 
(206) 685-7580 
MPH INDEPENDENT STUDY CONTRACT 


DIRECTIONS FOR USING THIS FORM: 
1) The student copies and pastes the entirety of this template into their email.  Fill out the email template at the appropriate blanks.
2) If the student is taking Independent Study credits at another University, the student must seek approval from Cindy Watts (watts@u.washington.edu) before proceeding.
3) The student uses their UW email account to send the completed form by email to their instructor 
4) The instructor fills out the appropriate section and sends the email to ExDP (uwedp2@u.washington.edu) and the student.

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Student Name: 

This contract must be completed and returned to the Extended MPH Degree 
Program Office (uwedp2@u.washington.edu)  before a student may register for ExDP INDEPENDENT STUDY (HSERV/EPI/ENVH 600) credits. 

The ExDP Program Director's (Cindy Watts: watts@u.washington.edu) approval is needed if independent study is being done at a college/university other than the University of Washington.  Copies of this form will be forwarded to the student and supervising faculty.  If registering for credits at the University of Washington, grade reports will automatically be sent to the Program Office at the end of the quarter.  If taken at another accredited university, students are required to provide a copy of the official grade report at the end of the quarter to ExDP. 

SUPERVISING FACULTY 

Faculty Name: 
Name of University: 
Department:	
Mailing Address OR Box Number: 
E-Mail: 
Phone: 


STUDENT

Student Name:  
Independent Study to begin (quarter/semester):
of year: 

Proposed number of credits: 

Final grade to be: (‘X’ one) 
_____ decimal grade 
_____ credit/no credit 


GOALS/OBJECTIVES: 


PRODUCT(S) OF STUDY (paper, literature review, etc.):