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					                                   UNIVERSITY OF MISSOURI-KANSAS CITY
                                     COLLEGE OF ARTS AND SCIENCES

                           RECOMMENDATION FOR APPOINTMENT OF PROGRAM,
                              DISSERTATION, OR EXAMINATION COMMITTEE

To:                    Graduate Officer, College of Arts and Sciences

Subject:               Recommendation for Appointment of Advisor or Supervisory/Examination Committee

Student’s Name:        ______________________________________________________________________

Degree Sought:                 Ph.D.           Major Subject: Psychology: Clinical Program

I wish to recommend that for the above mentioned student the following Committee be appointed:
_____ Program Committee
_____ Dissertation Committee
_____ Comprehensive Examination Committee

Committee Members:                                                      Department:

___________________________________________                   Psychology, UMKC Doctoral Faculty
(Chairperson)

___________________________________________                   Psychology, UMKC Doctoral Faculty

___________________________________________                   Psychology, UMKC Doctoral Faculty

___________________________________________                   Psychology, UMKC Doctoral Faculty

___________________________________________                   ___________________________________________

                                                              ___________________________________________
                                                              Approved by Director of the Psychology Ph.D. Clinical Program
This constitutes:

_____   The student’s initial committee
_____   Reconstitution of the student’s present committee
_____   An addition to the student’s present committee
_____   Other: ___________________________________


___________________________________________                   ___________________________
Department Chairperson                                        Date

___________________________________________                   ___________________________
Committee Chairperson                                         Date


APPOINTMENTS APPROVED:

___________________________________________                   ___________________________
Graduate Officer, College of Arts & Sciences                  Date

                                                                                                                       10/03
                UNIVERSITY OF MISSOURI-KANSAS CITY

                                   Department of Psychology


The undersigned have examined a dissertation proposal entitled:

_____________________________________________________________________________

_____________________________________________________________________________

presented by ______________________________________, a candidate for the degree of

Doctor of Philosophy in Psychology.



We hereby certify this proposal is accepted.


_______________________________ ___________________________________
(Dissertation Committee Chair)                                                (Date)

_______________________________ ___________________________________
(Committee Member)                                                            (Date)
_______________________________ ___________________________________
(Committee Member)                                                            (Date)
_______________________________ ___________________________________
(Committee Member)                                                            (Date)
_______________________________ ___________________________________
(Committee Member)                                                            (Date)




                                                ___________________________________
                                                Approved by Director Psychology Ph.D. Clinical
                                                Program


                                                ___________________________________
                                                Chair,
Psychology Dept. Form 10/03                     Department of Psychology
                          University of Missouri-Kansas City
                                      Department of Psychology


                                WAIVER OF M.A. THESIS

We the undersigned agree to waive the requirement for a Master's Thesis in Psychology based on the scope and execution

of the following described project, prepared by _____________________________________________ ,

Psychology Ph.D. Clinical Program student:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

________________________________________________________________________________________________



___________________________________                            ______________________________
(Committee Chair)                                                                                 (Date)


___________________________________                            ______________________________

___________________________________                            ______________________________

___________________________________                            ______________________________

___________________________________                            ______________________________
                                                               Approved by Director of Psychology Ph.D. Clinical Program



                                                               _____________________________
                                                               Chair, Department of Psychology




Psych. Dept. Form 10/03
                                    DOCTORAL DEGREE PROGRAM OF STUDY

In consultation with the Supervisory Committee, the student should
initiate this application, secure the approvals indicated below, and
present to the Dean or Graduate Officer for final approval.


         _______________________________________                   _________________________________________
         NAME (PRINTED OR TYPED)                                   SOCIAL SECURITY NUMBER

         _______________________________________                   _________________________________________
         CURRENT ADDRESS                                           DEGREE SOUGHT

         _______________________________________                   _________________________________________
         CITY, STATE                     ZIP CODE                  DEGREE PROGRAM AND EMPHASIS AREA

If you have received a Master’s or other advanced degree from an accredited university, please list below the degree title
(M.S., M.A., etc.); the total semester credit hours required for the degree(s), where taken, and date of degree award (to be
verified by the Supervisory Committee: see attached transcript).


Degree Title                       Total Degree Hrs Required       Institution                     Date Received



List below all courses proposed for your doctoral degree program over and above the courses taken for the degree(s)
listed above. At least 60% of the total number of hours taken at UMKC applicable toward this degree program must
be at the 500 or higher level. No more than one half of all Post-Baccalaureate work may be from another university.
Number                                   Hours      Grade     Number                                        Hours    Grade

           Title                                                        Title




                                                                        500 Level
                                                                                                    Total
                                                      REQUIREMENTS                                 Date Completed



RESIDENCY REQUIREMENT:                       _________________________________________________________________________________________

                                             _________________________________________________________________________________________


COMPREHENSIVE EXAMINATIONS (SPECIFY EXAMINATION AREAS)

                                             _________________________________________________________________________________________

                                             _________________________________________________________________________________________

                                             _________________________________________________________________________________________

                                             _________________________________________________________________________________________

DISSERTATION:                                _________________________________________________________________________________________

                                             _________________________________________________________________________________________

FINAL DISSERTATION EXAMINATION:              _________________________________________________________________________________________

                                             _________________________________________________________________________________________

***DEAN’S OFFICE will distribute copies of approved PROGRAM OF STUDY to REGISTRAR, STUDENT, and CHAIR OF SUPERVISORY
COMMITTEE***




SPECIAL REQUIREMENTS                                                APPROVALS


                                                                    Director of Psychology Ph.D.                                    Date
                                                                    Clinical Program


                                                                    Committee Chairperson                                    Date


                                                                    Member                                                   Date


                                                                    Member                                                   Date


                                                                    Member                                                   Date


                                                                    Member                                                   Date


                                                                    Member                                                   Date


                                                                    Department Chair                                         Date


STUDENT’S SIGNATURE                                   DATE           Dean or Graduate Officer                                Date


Adaptation of UMKC form No. 568B (10/03)1M
               UNIVERSITY OF MISSOURI – KANSAS CITY
                                      College of Arts & Sciences – Department of Psychology

                      REPORT OF RESULTS OF EXAMINATION FOR DOCTORAL STUDENTS

(     )   Comprehensive Examination                     Degree/Emphasis: Ph.D. Psychology Clinical Program


 (    )   Final Dissertation Examination


 This is to certify that _________________________________________________________________________
                                              (Name of Student)

 passed / failed the above-indicated Examination on __________________________________________________.


 Comments:



 Evaluation [Superior, Good, Fair, Inferior (failed)]          Signatures (Examining Committee)

     _______________________________                           ________________________________________ (Chair)

     _______________________________                           ________________________________________ (Member)

     _______________________________                           ________________________________________ (Member)

     _______________________________                           ________________________________________ (Member)

     _______________________________                           ________________________________________ (Member)

                                                               ________________________________________
                                                               Director, Psychology Ph.D.
                                                               Clinical Program




If a Final Dissertation Examination, please furnish title:




 This form is to be completed in duplicate and sent to the Graduate Records Office within 48 hours of the completion of
the Examination.
                                                                                                              PsyDept 10/03
                                   DEPARTMENT OF PSYCHOLOGY

             PRELIMINARY APPROVAL OF DISSERTATION PROPOSAL


TO:                  SOCIAL SCIENCES INSTITUTIONAL REVIEW BOARD




THE SUPERVISORY COMMITTEE FOR


______________________________________________________________________________
       (Student's Name)


A DOCTORAL CANDIDATE IN PSYCHOLOGY, HAS REVIEWED THIS DISSERTATION


PROPOSAL AND FINDS IT ACCEPTABLE.




____________________________________                    ______________________________
(Supervisory Committee Chair)                                        (Date)


____________________________________                    ______________________________
Approved by Director Psychology Ph.D Clinical Program                (Date)




Psych. Dept. Form
10/03

				
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