Alternative Award For Credit Request Form
ADVERTISEMENT
1ALTERNATIVE AWARD FOR CREDIT REQUEST FORM
To request Alternative Award of Credit based on licensure or certification, follow the directions below:
1. Complete this form and include the following documentation:
a. Attach a copy of the appropriate Alternative Award of Credit Agreement
b. Attach a copy of the current designated License or Certificate
c. Attach a copy of the Alternative Learning Application for each course with fees.
2. Send ALL required documentation to the Health Information Technology (HIT) Program Director for verification and
approval.
3. The Business Division Chair and/or the HIT Program Director will review the documentation and verify that you have
met the required criteria for the credit to be awarded per the Agreement.
4. Once the Alternative award of Credit has been approved, both the Business Division Chair and HIT Program Director
will sign the Alternative Credit Award Form and Award of Credit Agreement Form, attach the required documentation
and forward it to the Records Office to be processed.
Student Name: _______________________________ CC ID# _________________________
Major: ______________________________________ Catalog Year: ____________________
CC Email: ___________________________________ Daytime Phone: __________________
Please check the appropriate Award of Credit Agreement you are eligible for:
AAS Degree Program
Certification
State Code
Cr
□
Health Information Technology AAS
Local
14
Certified Coding Associate (CCA)
□
Local
14
Certified Coding Specialist (CCS)
□
Local
14
Certified Professional Coder (CPC)
Identify the documentation you are attaching to verify you have met the criteria for alternative credit:
□
Copy of _________________________________________________ License
□
Copy of _________________________________________________ Certificate/Certification
_______________________________________________
_____________________________
Student Signature
Date
Approval
Please award ______ credits to the student for the ______________________________________ licensure/certification.
The student has provided the required documentation and completed the necessary course work as specified in the
_________________________.
Award of Credit Agreement. Please list the state code if applicable:
__________________________________________
_______________________________
Health Information Technology Program Director
Date
_________________________________________
_______________________________
Business Division Chair
Date
Revised 3/2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Education