Certificate of Research Leadership

Record of Participation in Outside Activity

This form is intended to document participation in activities if offered outside MSU (or if no sign-up sheet was available).  Please complete the information below and submit to [email protected].  Forms should be submitted immediately after attendance rather than all at one time.

• Download a word version of the Outside Activity form here

Faculty Name: ____________________________________________________________________________________________

Department: ______________________________________________________________________________________________

Date(s) of Activity: __________________________________________________________________________________________

Total Hours of Attendance: ___________________________________________________________________________________

Title:  ____________________________________________________________________________________________________

Sponsoring Organization: _____________________________________________________________________________________

Location: __________________________________________________________________________________________________

Brief Description:

 How I will Incorporate what I learned:

Your Signature:____________________________________________________________________________________________