OCR Staff Signature: Approval Form

 Approval Form‐ External Course OCR Human Subjects Workshop Requirement
Submit to the OCR c/o Rosalyn McNeill at [email protected] PART I – CRC CONTACT DETAILS Attendee: Penn Address: City, State & Zip: Phone: Email: ____________________ PART II – CORE COURSE DETAILS Course Title: Course Date: Hours Requested: (instructional time ‐ do not include registration or breaks) Program Type:  Workshop  Conference  Webinar  University Course  Other PART III ‐ REQUIRED ATTACHMENTS (All attachments must be submitted along with this completed form)  Course Curriculum (Program Description)  Verification of attendance (Letter, certificate, registration form, other)  Learning Objectives PART IV‐ PROGRAM CONTACT DETAILS Program Provider: City, State & Zip: Phone: _______ ______________ Address: Contact Person: Email: OCR Staff Signature: PART V‐ REVIEW BY OCR  Date Received ___________  Date Processed____________  Approved  Number of Credits_______  Additional Documents required_______________________________________  Course does not meet criteria for HSR work shop credit  Reviewed by Initials_______