Collaborative Decision Making Through Shared Governance

Collaborative Committee Meeting Verification Form

Students must submit this form to the course faculty along with written assignment.

Student Name:__________________	Course Section & Faculty Name:_____________________________
Committee Information
Committee Member Name :
Last	First	M.I.
Credentials:		Title:
(e.g., MS, RN)
Organization:
Phone Number:
E-mail Address:
Committee Setting
Health Care Organization	Community Center	Prof. Organization	Local School
D
Provider Acknowledgement

I, __________________________,acknowledge that ____________________________

(Member Name) (Student Name)

has attended the committee meeting listed on this form. The organization/agency does not endorse the University or the student, however the observational experience selected by the student is considered an appropriate learning experience.

______________________________ _________________

Member Signature Date Signed