zilongwang/ReadingBank huggingface dataset:
Application to place a builder’s skip on the highway (LHA01) Highways Act 1980, Section 139, 140 and 140A You must give minimum notice of five working days before you intend to the skip on the road. The skip may not be placed on the highway without written confirmation that the permit has been authorised. Proposed location of the skip Name of applicant: Address (including postcode): Telephone (out of Email address: Dates: (from) (to). Skip operator or details Name: Address (including postcode): Telephone: Email address: Declaration I/we hereby to North Somerset Council for permission to place (number) builder’s skip(s) on the highway at the location stated on this form and hereby agree to comply with the terms and conditions set out as attached and with all other statutory rules and regulations which may apply in these circumstances. Fee enclosed: Signed: Position in company: Name (block capitals): Date: Data Protection Act 1998 The personal data you provide on this form will be used by North Somerset Council to administer your permit. In order to protect public safety, this may include the use of sensitive personal data (criminal offences) to help assess whether you are a fit and proper person to hold a permit. We may occasionally share your personal data with other council departments and with other bodies including (housing benefits, the police, Inland Revenue) for the purposes of protecting public money, preventing and detecting crime and/or fraud and ensuring public safety. Such sharing will only occur on a case-by-case basis where a justifiable purpose in line with legislation has been demonstrated. The information may also be used for internal training. ______________________________________________________________________________ For office use only Licence number: Confirm reference: Granted Refused Receipt number: Application notes
Education and qualifications What was the highest year level you completed? What high school did you attend? What other certificates or courses have you studied? Course/ Certificate/ Qualification Organisation Year Employment history and status Current occupation: Previous jobs Job Organisation Year Have you worked as an interpreter before? Yes / No If yes, what areas have you worked in e.g. Police/ Medical/ Courts etc. Current availability Please indicate your current availability for training and casual work Anytime OR Please circle availability Mon Tues Wed Thurs Fri Sat Sun AM AM AM AM AM AM AM PM PM PM PM PM PM PM
Applicant’s Name: Last: First: M.I. Address: (Current or Last Please check if: Shelter Temporary Housing Numbers: Mobile: Home: Alternate or Email: Homeless: Yes No Veteran: Yes No Date of Birth (MM/DD/YYYY): Age: Social Security #: Gender: Male Female Transgender Sexual Orientation (Optional): Race: Marital Status: Primary Language: Interpreter Required: Yes No U.S. Citizen Legal Resident Highest of School Completed: Employment Status: Mental Health Diagnoses (please list all you and your doctor have identified): What stands in the way of you completing the things you need to do? Why are you applying for services? What are your What daily activities and skills do you want assistance with or do you think you don’t do well when you are not feeling well. Please check all that apply: Personal hygiene and grooming Food preparation Making healthy food choices Meeting new people Using supports Doing well in school Staying safe Exercising Keeping room/home clean Managing budgeting Getting along with friends Getting/using resources Using transportation Other: Following housing rules Taking medications consistently Accessing resources Getting with family Getting and keeping jobs Making good decisions Other: Somatic/Physical Health Diagnoses or Concerns: Previous History of Drug and Alcohol Use (please include type, when used, in what amount, and how used): Current Drug and Alcohol Use (please include type, when used, in what amount, and how used): Current Medications – type, frequency, dose and reason for taking: Have you been hospitalized for mental health reasons: yes no If yes, list dates, duration and reasons:
Structures on designated land Several within the ACT require Works Approval from the National Capital Authority for the erection of any structures such as marquees or jumping castles. You will be advised if this requirement applies upon application. Additional conditions Approval for an event or activity may include site or event-specific conditions as determined by TAMS. Failure to comply with the conditions of a public unleased land permit is an offence under the Public Unleased Land Act 2013.
Animals Requested: Where will animals be obtained and are there any special shipping requirements? If these are privately owned animals please attach an owner consent form Are agricultural animals obtained from a non-traditional source such as poultry from a commercial production company or from commercial herd? Yes No If yes, please describe how the animals are tested and determined to be free of diseases which could potentially infect other animals on site, and any special precautions, such as quarantine isolation housing that is required. 12. Where will animals be housed (or captured for wildlife)? Will any untreated or non-manipulated animals be humanely euthanized, to obtain tissue, cells, etc.? Yes No If Yes, list types of tissue, etc: Dietary Manipulations Yes No If Yes, list and explain (Note: if food or fluid will be restricted, describe method for assessing the health and wellbeing of the animals. Body weights must be recorded at least weekly. Amount earned (if animals work for food or fluid) during testing and amount freely given must be recorded. A scientific justification must be provided for departures from the recommendations of the Guide.) Environmental Stress (e.g. cold, prolonged restraint, forced exercise, shock) Yes No If Yes, list and explain:
Application to use non-organic seed This form should be used for single varieties of seed, grass/forage seed mixes, seed potatoes and other planting material. Please read the guidance overleaf and the notes below when completing the form. Farm name Licence number Supplier of grass/forage seed mix Percentage of organic seed used on your holding Percentage of organic seed in mix Crop Variety1 Seed quantity (kg/no)2 Reason for request3 Justification for use of non-organic seed4 Proposed planting date Notes 1All non-organic varieties that require approval must be listed. For a seed mix, please list the non-organic varieties in the mix and confirm the percentage of organic content in the top right corner. 2Please specify whether the figure entered here refers to kilograms, grams or number of seeds. 3You must choose from reasons (a) to (e) as listed on the front of the form. 4You must give further details here unless you have requested reasons (a) or (e). For help completing the form, please call the producer certification team on 0117 914 2412.
Submit copies of this completed and signed application and all required documentation of successful course completion for all courses to (Name & Contact information for approving OTI Education Center) along with a check, credit card, or money order for $95 (enter respective OTI Education Center payment processing information). Required documentation is either a course completion certificate or official transcript from the OTI Education Center where the course was completed. Item 1 Applicant Name List full legal name. Item 2 Title List current job title. If currently not working, leave this field blank. Item 3 List current employer. If currently not working, leave this field blank. Item 4 E-Mail List a current email where you may be contacted. Item 5 Applicant Address Provide a current address, phone and fax number where you may be contacted. Item 6 Completed Course(s) Check the box which corresponds to the applicable OSHA course(s) completed. OSHA Course Prerequisites Must have complete the three (3) required courses: OSHA #511 Occupational Safety and Health Standards for General Industry OSHA #7500 Introduction to Safety and Health Management OSHA #7505 Introduction to Accident [Incident] Investigation Must have complete a minimum of four (4) of the following elective courses that include a minimum of 29 contact hours of training: OSHA #3095 Electrical Standards (26 hours) OSHA #521 OSHA to Industrial Hygiene (26 hours) OSHA #2255 Principles of Ergonomics (26 hours) OSHA #2264 Permit-Required Confined Space Entry (20 hours) OR OSHA #7300 Understanding OSHA's Permit-Required Confined Space Standard (7 hours) OSHA #7000 OSHA Training Guidelines for Safe Patient Handling (7.5 hours) OSHA #7005 Public Warehousing and Storage (7 hours) OSHA #2045 Machinery &Machine Guarding (26 hours) OR OSHA #7100 Introduction to Machinery and Machine Safety Guarding (4 hours) OSHA #7105 Introduction to Evacuation and Emergency Planning (4 hours) OSHA #7115 Lockout/Tagout [Controlling Hazardous Energy to Prevent Workplace Injury] (7.5 hours) OSHA #7200 Bloodborne Pathogens Exposure Control for Healthcare Facilities (7 hours) OSHA #7205 Health Hazard Awareness (6 hours) OSHA #7210 Pandemic Influenza and Workplace Preparedness (5.5 hours) OSHA #7845 Recordkeeping Rule Seminar (4 hours)
7.5 Is the site within the 1% AEP flood area (Annual Exceedance Probability or Q100)? 7.6 Is the site well drained? (i.e. natural or man-made?) 7.7 Setback distances from the land application area to the nearest: Bore Watercourse, Lake, Dam Building Swimming pool Driveway, paved surface Site boundary metres metres metres metres metres metres 8.0 WASTEWATER END USE 8.1 Identify the end uses for the treated water, or residual liquid from a dry composting toilet. (select ALL options) Note. Disposal of septage in remote areas must be in accordance with DoH requirements Infiltration/soil absorption trench Evapo-transpiration bed/trench Mound Subsurface irrigation Surface irrigation Toilet flushing 8.2 Land area available for disposal (m2) 8.3 Size of effluent disposal area (m2) 8.4 Identify the end use or deposition of the sludge or composted biosolids (select ALL options) Tankered off-site to a sewage treatment plant Discharged to sewer Composted and buried on-site Composted and taken off-site Not applicable (no residual sludge / compost does not need to be extracted) Other: 9.0 MAINTENANCE 9.1 State the maintenance or servicing intervals as required in the Manual Maintenance / Service is required every ……….. months. The regime is detailed on page ….. of the ………….. Manual
1547:2012) of soil as determined by the soil classification in 6.2 7.4 Is the site likely to be subject to flooding or inundation? 7.5 Is the site within the 1% AEP flood area (Annual Exceedance Probability or Q100)? 7.6 Is the site well drained? (i.e. natural or man-made?) 7.7 Setback distances from the land application area to the nearest: Bore Watercourse, Lake, Dam Building Swimming pool Driveway, paved surface Site boundary metres metres metres metres metres metres 8.0 WASTEWATER END USE 8.1 Identify the end uses for the treated wastewater (select ALL options) Municipal irrigation (specify) Crop irrigation (specify) Soil Aquifer Treatment (specify) discharge subject to NT EPA WDL (specify) Passive usage / ornamental (specify) Dust suppression (specify) Other non-potable use (specify) 8.2 Proposed irrigation options Surface irrigation:
Have any of your daughter’s relatives ever had any of the following Alcoholism/Addiction Who: Describe Kidney Disease Who: Describe Cancer Who: Describe Mental Illness Who: Describe Heart Disease Who: Describe Tuberculosis Who: Describe Depression Who: Describe Bipolar Disorder Who: Describe Schizophrenia Who: Describe Other illness in the family Who: Describe
Student History A surprising number of what are considered “normal” children may exhibit some of the behaviors and characteristics in an attempt to create an image and are not indicative of any serious psychological problems. Any comment you may have on these would be beneficial in our work with your child. Please all that apply to your child. Accident Alcohol use Aggression towards others Alienation from parent/s Anxiety Blacks out Bedwetting Blames others Bullies Basically unhappy Binges and/or purges Car theft Cutting on herself Cruelty to pets or animals Cries easily or often Complains a lot Defiant Destroys property Difficult to control Dishonest Dare Devil Behavior Depressed mood Denies mistakes Denies mistakes Does not like touched Drug use Easily frightened Excitable Frustrated easily Fire setting Gang involvement Irritable Impulsive Intimidated by others Internet addiction Isolates Lack of motivation Lack of remorse Lies Manipulative Manipulated easily by others Mood swings Overeats Obnoxious Obnoxious Panic Attacks Poor concentration or attention span Poor hygiene Phobias Physical violence Quarrelsome Rage attacks Starves herself Suicide threats Suicide attempts School failure Sexually acting out Sexual identity issues Seeks attention Sneaky and/or deceptive Shy or timid Strange thoughts disturbances Theft Threatens others Truancy Threatens others Truancy Temper tantrums Vandalism Verbally abusive Violence Withdrawn Weapons
Tulare CAG (TCAG) Porterville YES 3/29/2013 to TCAG Christine Chavez 5955 S. Mooney, (559) 624-7270, email: mdemmers@co.tulare.ca.us
Use discretion in selecting evidence that relates specifically to compliance criteria. CMS does not need to see every sign-in sheet, every completed activity evaluation form, (a summary is better) or faculty CVs. However, all signed written agreements must accompany a list of commercial supporters, if commercial support was received. And disclosure information for all those in control of content is required. Remember that forms and checklists alone do not verify performance in practice. Once you have affixed the to the evidence or coversheet, HIGHLIGHT your demonstration of compliance. One sentence or paragraph within a five-page document may be your demonstration of compliance! It is important that you show how and where you are in compliance! Assembling an Activity File Evidence for each activity selected must be submitted in an 8 ½” by 11” file folder; do NOT submit evidence in binders. Leave pages loose, do not staple or bind. Affix a label on the front cover of the file folder that specifies: Full name of organization (no acronym) Activity title as it appears on the CME Activity List Activity date and location as it appears on the CME Activity List; any variation must be explained Type of activity (Your only choices are Course, Internet Activity Live, Internet Activity Enduring Material, Enduring Material, Journal CME, Journal-based Manuscript Review, Test Item Writing, Committee Learning, Performance Improvement, Learning from Teaching, Internet Searching and Learning, or RSS) Directly or jointly sponsored activity If commercial support was accepted. Enclose the CME Product for Enduring Material Please submit the CME product in its entirety for each Internet, journal-based and/or enduring material CME activity selected. For Internet activities provide a direct link to the online activities or the URL, and a username and password, when necessary. If an Internet activity selected is no longer available online, you may submit the activity saved to CD-ROM or provide access on an archived web site. If surveyors have difficulty accessing the activities or finding the required information, you will be expected to clarify this evidence at the time of the interview. Active URLs, login IDs and passwords must be made available for the duration of your organization’s current accreditation review. Submitting Materials to CMS Please send the following materials to CMS:
Phone: My disability is: If it’s the first time you have worked with us, and you have a diagnosis of Intellectual Disability or Autism Spectrum Disorder, please attach relevant specialist reports. For all other diagnosis you can ask your doctor or specialist to fill out a ‘Confirming your disability’ form. This is available on our website: I also live with these medical/mental health/accident-related conditions: 4. Reasons for application How urgently do you feel that you need support in your current situation? Non urgent (application progressed within one week) Semi urgent (application progressed within 2 days) Urgent (application progressed within 1 day) Describe the reasons for your application. What do you need support with because of your disability? Describe any safety, hazards or sensitive issues that AccessAbility staff need to know about. What other people or organisations are you working with? This includes places you currently receive support from. Specialist: Social worker: Therapist: Psychologist: ACC: Paediatrician: Agencies:
Market/Employment Data 1. Local Workforce Investment Area () LWIA Area 2. Most recent projection percent for rate of employment growth (LWIA) 3. Most recent projection for number of new jobs (LWIA) 4. Most recent projection percent for rate of employment growth (Commonwealth) 5. Most recent projection percent for employment change (National) 6. Most recent projection percent for rate of employment growth across all occupations (LWIA) 7. Most recent projection percent for rate of employment growth across all occupations (Commonwealth) Occupation: Pathway: Occupation: Pathway: Occupation: Pathway: Occupation: Pathway: Occupation: Pathway:
The Agency for Health Care Administration all documents for electronic storage. In an effort to facilitate this process, we ask that you please remember to: Please place checks or money orders on top of the application Include license number or case number on your check Do not submit carbon copies of documents Do not fold any of the documents being submitted No staples, paperclips, binder clips, folders, or notebooks Please do not bind any of the documents submitted to the Agency.
SUNY| ID ___________________ APPLICATION FOR GRADUATE ADMISSION I am applying for the following Certificate in Executive Management Program: [ ] Strategic Thinking [ ] Marketing & Management [ ] Corporate Financial Management [ ] Competitive Project Management [ ] Business English First Lessons When do you plan to enroll? [ ] January (SUNY – Albany) [ ] July (SUNY – New Paltz) Year: _________ Additional application material will be sent to your academic advisor Passport Number: Birth date (dd/mm/yyyy): Legal Name: Last First middle names Mailing Address: Street Number City State Zip Code Phones: Home Business Cell e-mail: Name of Employer Current Position Country of Birth _____________________________________________ Preferred T-shirt size: [ ]S – [ ]M – [ ]L – [ ]XL Educational Background List below the College you attended and Major Name of College City State Graduation Date
Date : Signature of Applicant Place :______ Note : The application form must be accompanied by the AAU copy of challan against the payment of fee (Rupees Three hundred for General Category and Rupees One hundred & fifty for SC/ ST/ PH candidates). Send applications along with self attested copies of all relevant testimonials and certificates etc. 3. Incomplete applications or the applications received after the due date shall not be considered in any case. Assam Agricultural University, Jorhat APPLICATION FOR DIRECT RECRUITMENT TO THE POST OF ASSOCIATE PROFESSOR (Stage 4) AND EQUIVALENT To, The Registrar Agricultural University Jorhat 785013 () (Through Proper Channel) Sir/Madam I, ………………………………………………………hereby for the post of ………………………………………………….in in response to your advertisement in ………………………………………….. The filled in proforma and supporting documents are enclosed for favour of consideration.
Date & Signature of applicant……………………. Name of applicant:……………………….. AGRICULTURAL UNIVERSITY, JORHAT APPLICATION PROFORMA FOR DIRECT RECRUITMENT OF ASSOCIATE PROFESSOR (Stage 4) AND EQUIVALENT (To be supported with necessary documents/evidences, each marked with separate enclosure number) Name in full (block letters): Present Designation, if employed: Present address: Discipline: Date and place of birth: Father’s name/Husband’s name: Particulars of service in the rank of Assistant Professor: Category of post Designation , Institution/ Organization with Place of posting Period Duration From (date) To (date) Years Months Days a) Teaching
b) Research c) Extension Total Date of joining in the post of Assistant Professor (Stage 3) & equivalent with AGP of Rs. 8000.00: b. Date of completion of 8 years in the rank of Assistant Professor: Date of acquiring Ph.D. Degree (actual date of thesis viva voce): Period in obtaining Ph.D. Degree: ………Years………Months………..Days 8. Refresher course/Research methodology course/Summer institute/Winter school/ Training programme attended during the assessment period (enclosed document nos. …………………. ): Sl. No. Title of course/ programme Duration Place Organization From (date) To (date) 9. Seminar/Conference attended during the assessment period (enclosed document nos…………………..) Sl. No. of seminar/ conference Duration Place Organized by Whether oral/poster presentation or attended of paper presented From (date) To (date)
Refresher course/Research methodology course/Summer institute/Winter school/ Training programme attended during the assessment period (enclosed document nos. …………………. ): Sl. No. Title of course/ programme Duration Place Organization From (date) To (date) Seminar/Conference attended during the assessment period (enclosed document nos…………………..) Sl. No. Title of seminar/ conference Duration Place Organized by Whether oral/poster presentation or attended Title of paper presented From (date) To (date) 10A. Brief summary of salient achievements during the period of assessment (extra pages may be added, if required)
The Assoc. Director of Research/Extension Education, AAU, Jorhat/ Khanapara-22. All Chief Scientists/Programme Co-ordinators, AAU, Outstations. Dr. A. Saikia, Professor & Web Master, Deptt. of Horticulture, AAU, Jorhat. He is requested to incorporate the (enclosed) Advertisement in the AAU website The System Administrator, ARIS Cell, AAU, Jorhat. All of the Departments, FA/FVSc/ FHSc, AAU, Jorhat/ Khanapara. 13. The Registrar(Acad.), AAU, Jorhat/Khanapara, Guwahati-22 14. The In-charge, Employment Exchange, AAU, Jorhat. Registrar, Agricultural University, Jorhat-785 013.
Language Proficiency attained* Examination passed, if any * State whether you can speak, read or write. 17. Present occupation with 18. Previous appointment/work experience in chronological sequence starting with the first appointment (Enclose employer’s certificate(s), Enclosure no.(s)__________ : Sl. No Post held Employer/ Organization Last pay drawn with pay scale Date of joining Date of leaving Period (Till the last date of receiving application) Nature of duties in (Teaching/ Research/ Extension/ Any other Years Days
total total API Year-wise for the assessment period *Enclosure nos. of supporting documents Max. score **Score of 1 2 3 4 5 6 7 8 A Teaching 15 A01 Courses taught etc. 8 A02 i)Preparation of Teaching manual etc. ii)Guidance of PG esearch a)As Advisor b) As Member, Advisory Committee 7 B Research 15 B01 Involvement in AICRP etc. 4 B02 i)Involvement in externally funded etc. ii)Involvement in contract etc. 7 B03 Technologies developed etc. 4 C Extension 15 C01 Service provided in KVK etc. ii)Involvement in/Conduct of extension Training etc. 4
societies awards etc. iii)Best paper, best poster award iv) Invited key speaker etc. v) Special assignments etc. vi) Convener/ Organizing secretary etc. vii) Course Director/Course Coordinator etc. viii) etc. ix) Technical Scientist x) External question paper setter etc. xi) International projects etc. F #Interview 20 # 100 *Supporting documents to be enclosed separately; and each document should bear an enclosure number at the top **Scoring must not exceed the maximum score specified in the relevant Score Card Guidelines # Not to be filled in by the applicant (Score to be assigned by the Screening Committee/Selection Committee)
Seminar/Conference attended during the assessment period (enclosed document nos…………………..) Sl. No. Title of seminar/ conference Duration Place Organized by Whether oral/poster presentation or attended Title of paper presented From (date) To (date) 10A. Brief summary of salient achievements during the period of assessment (extra pages may be added, if required)
Please check all funding categories that apply (if more than 1 category, please rank in order of primary “1”, secondary “2”, etc.) Children & Families Foster Care Elderly Services Criminal Justice Autism Adult General Does this project address an identified QOL priority issue? Yes No Please check all that apply (if more than 1 priority issue, please rank in order of primary “1”, secondary “2”, etc.) Obesity Affordable Housing Elderly Services Access to Health & Human Services Child Abuse Prevention Delinquency Prevention & Diversion Unemployment Criminal Justice Foster Care Veterans Reintegration Maternal Health & Infant Mortality School Size Autism Transition Skills/Programming Family Strengthening Early Literacy Mental Health List all NSU colleges/centers involved in this collaboration and the name of the respective dean(s). **All faculty of the Abraham S. Fischler School of Education must obtain approval and Dean’s signature to submit a proposal for the Quality of Life Faculty Community- Based Applied Research Grant. Dean’s Signature Date
Additional PI Name PI Status? Contact Information Description of the roles, responsibilities and the working relationship to the primary PI. Downstate Faculty Member KCHC Employee with Clinical Privileges Other. Specify: Phone # Email : Downstate Faculty Member KCHC Employee with Clinical Privileges Other. Specify: # Email : Downstate Faculty Member KCHC Employee with Clinical Privileges Other. Specify: # Email : Note: Attach additional sheets if needed. The first PI listed in the IRB application must be affiliated with the Downstate or KCHC and will serve as the contact PI. Each PI must electronically sign the initial submission. If adding staff (even if listed in response to question E), complete the following chart with the new staff member’s information (If additional space is needed, please continue on a separate page using the same format): a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier?
If Yes to A, are you making changes to the study recruitment methods or recruitment documents for this site? Yes No NOTE: Any Downstate representation on social media must be authorized by SUNY Downstate’s Office of Institutional Advancement after IRB approval is granted. See: If Yes to D, Select all that apply: Flyer Information Brochure Radio/TV Direct Subject Contact Letters Referral Printed Ad Radio/TV Internet Posting: Website: Other: Social Media; Describe: If revised, please upload a copy of the revised recruitment documents with tracked changes, underlined or highlighted to the Designer page of your IRBNet submission package If revised, please upload a copy of the revised or new recruitment documents. STUDY SITE CHANGES: Are you making changes to the list of sites taking part in this study? Yes No IF NO, Proceed to the next section.
Course ID___________________ Developer____________________________________________ NOTE: It is not necessary to submit this checklist with the New Course Application. It is provided to assist the course developer in ensuring that all essential syllabus elements are addressed. The checklist is used by the Adams Center in syllabus review. All items below are required unless otherwise marked. About the Course ¨ Course number and title ¨ Credit hours ¨ Semester and year ¨ Meeting time and place ¨ Pre-requisite/co-requisite About the Instructor(s) ¨ Name and title or rank ¨ Office location ¨ Phone number(s) ¨ Email address ¨ Office hours / contact expectations Mission Statements ¨ ACU mission statement ¨ College mission statement ¨ Departmental mission statement ¨ Personal mission statement (optional) Unique Christian Perspective ¨ Description of how learning and Christian faith are integrated in the course Course Content ¨ Catalog description ¨ Intended audience ¨ Outline of topics ¨ Format of course/types of activities student should expect in the course Teaching/Learning Methods and Format of Class Sessions ¨ Description of the types of activities students should expect in the course Materials ¨ Required and optional materials, including textbooks, etc. Learning Objectives/Competencies ¨ Specific competencies stated in measurable terms ¨ Assignments or instruments that will be used to assess the competencies. Assessment/Grading Criteria ¨ Complete and accurate details of factors and elements that will comprise the grade. ¨ Weight or point value of all graded elements ¨ Grading scale with expectations for letter grades ¨ Extra credit opportunities (optional) University Policies ¨ Special needs policy - ADA ¨ Academic integrity policy (recommended) ¨ Title IX policy (recommended) Course Policies ¨ Expectations and consequences regarding: o Attendance and Tardiness o Participation o Course specific academic integrity policy (optional) Course Calendar (Note: Calendar is not required for Course Application, but it must be included in all syllabi distributed to students.) ¨ Exam dates ¨ Assignments ¨ Due dates and other deadlines o Late assignment/exam policy ¨ Schedule of readings and topics ¨ Statement to reserve right to modify the calendar as necessary Writing Course Competencies
To be submitted for a substantial increase or decrease (a cumulative modification of 25 percent or more from the original date of program recognition or the most recent accreditation review) in the clock hours or credit hours of an existing approved program (Section IV (E)(6)(a)(i), Rules of Process and Procedure, Standards of Accreditation). School # Name of School Main or Branch City State Degree Granting Contact Person Phone Email 1. Type of Substantive Program Modification (Please Check All That Apply): Change in Clock Hours Change in Credit Change in Type of Credit Hours Substantive Change in the Type of Credential Awarded (e.g., occupational to academic associate degree) 2. Program Information Prior to the Modification: Program Instructional Clock Hours Total Clock Hours and Outside Prep Hours Total Credit Hours Type of Credit Hours Full Credential and Abbreviation Externship Information (Externship hours as listed on the Outline of a Degree Program; may include multiple courses) Semester Total Clock Hours Quarter Credit Hours 3. Program Information After the Modification: Program Title Instructional Clock Hours Total Clock Hours and Outside Prep Hours Total Credit Hours Type of Credit Hours Full Credential and Abbreviation Externship Information (Externship hours as listed on the Outline of a Degree Program; may include multiple courses) Semester Clock Hours Quarter Total Credit Hours I certify that the information herein and attached hereto is correct. Name Signature Title Date ELECTRONIC SUBMISSION FORMAT REQUIREMENTS: Electronic Submissions may not be transmitted to the Commission via e-mail. All electronic documents must be submitted in accordance with ACCSC’s . Submit the electronic documents to ACCSC using a CD, DVD, or flash drive medium that has been prepared using Adobe Acrobat software. A “Portable Document Format (.pdf) file” means that the electronic document has been assembled into one file, not a series of separate files.
Application for Employment Personal Information Date: Email: Last Name: First: Middle: Street Address: City/State/Zip: Mobile Phone: Alternate Phone: Any other names you have been known by: Job Questions Please answer the following questions as thoroughly as possible. Failure to complete the application may prevent you from being considered for employment. Which hours or shifts are you willing to work? Please also indicate in which areas in the Twin Cities Metro you are willing to work. What is your preferred employment status: ☐ Part Time ☐ Full Time ☐ On Call Are you 18 of age or older? ☐ Yes ☐ No Do you have a valid driver’s license? ☐ Yes ☐ No Are you able, either with or without reasonable accommodation, to perform the essential functions of the job for which you are applying? ☐ Yes ☐ No Are you legally eligible for employment in the United States? ☐ Yes ☐ No Have you ever applied to our company before? ☐ Yes ☐ No If yes, when? Have you ever worked for our company before? ☐ Yes ☐ No If yes, when and where? What date are you available to begin training? May we contact your current employer(s)? ☐ Yes ☐ No May we contact your previous employer(s)? ☐ Yes ☐ No Are you proficient in American Sign Language? ☐ Yes ☐ No Please list any additional languages- please clarify if you are able to speak and/or read the language: Employment History
SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? FEDERALLY FUNDED STUDIES ONLY f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
3 Age Group 16 – 25 26 – 35 36 – 45 46 – 55 56 – 65 66 – 70 Over 70 Prefer not to say 4 Disability Do you consider yourself to have a disability or a long term health condition? Yes No Prefer not to say 5 Marital Status Single Separated Married Divorced In a civil partnership Civil partnership dissolved Married to a person who has been previously married whose former spouse was still living at the time of the marriage Widowed Divorced and remarried with a previous spouse living at the time of the marriage Prefer not to say ? Form dated March 2015
SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? FEDERALLY FUNDED STUDIES ONLY f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
SUNY Downstate UPB NYC+HH, Kings County Other: Yes No SUNY Downstate UPB NYC+HH, Kings County Other: Yes No SUNY Downstate UPB NYC+HH, Kings County Other: Yes No SUNY Downstate UPB NYC+HH, Kings County Other: Yes No SUNY Downstate UPB NYC+HH, County Other: Yes No COMPLETTION OF SECTION 3 IS OPTIONAL IF AN EXTERNAL irb IS USED: Background, Alternatives, Eligibility, Precautions, Benefits, Risk , and Justification: Describe the condition or disease for this request: Describe the eligibility (inclusion) criteria for this request: Describe the exclusion criteria for this request:
Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. written Informed Consent/Authorization purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
If YES, please explain for what purpose the specimen will be used If your study involves tissue banking, please fill out the following 6 questions below: What type of research is to be done with the specimens? (e.g. in the future etc…) Describe how and where specimens will be stored. If specimens will be linked to individually identifiable information (e.g. name, ID#, code) describe how the privacy of research participants and the confidentiality of their data will be protected: Describe who will have access to the specimens including the requirements for access, and who has control of this access: Describe the procedures in place for research participants to withdraw their specimens or whether de- identification makes withdrawal impossible: Is the banking of the specimens optional? Yes No. If NO, the informed consent should adequately explain that participation in the means the specimens will be stored indefinitely for future use or explain when the samples will be destroyed. 12) PRIVACY & CONFIDENTIALITY What will be done to ensure the privacy of the research participant? (e.g., use of curtains, drapes, closed room) What will be done to ensure the confidentiality of the research participants data ? (e.g. data access, data security, data disclosure, destruction of identifiers, storage, and coding)
SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
Recruitment of prisoners Yes No Recruitment of students or employees Yes No Data from a NYC School Yes No TABLE OF STUDY STAFF: For training and conflict of interest disclosure requirements see: a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous specimens) to be transported by a public carrier? SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No
a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC H + H, KC Other: Yes No Yes No Yes No SUNY Downstate NYC + H + H, KC Other: Yes No Yes No Yes No
SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
Data from a NYC School Yes No TABLE OF STUDY STAFF: For training and conflict of interest disclosure requirements see: a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. Place of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No
a. Name & degree b. Role(s) on Project. Examples: Principal Investigator, Coordinator, Consultant, Fellow, Resident, Student, Research Staff, Healthcare Operations only, Access to de-identified data only, Specimen shipment, etc. c. of employment REMINDER: is also required for all NYC H+H research. d. Will this person be obtaining verbal or written Informed Consent/Authorization e. Is this person an “Investigator for the purposes of COI reporting”? THE PI IS ALWAYS CONSIDERED AN INVESTIGATOR FOR COI PURPOSES. f. Will this person aid the shipment of hazardous materials (e.g., dangerous goods, specimens) to be transported by a public carrier? SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Yes No Yes No Yes No SUNY Downstate NYC +HH, KC Other: Yes No Yes No Yes No