Directions: The 4+1/3+2 (Existing Program) Change Request Form is to be used to propose a 4+1/3+2 degree program (baccalaureate + master’s level) using two existing degree programs. This form will be used to provide necessary administrative information and justification for the proposed program expansion. Note: For analytical support regarding justification, contact Program Analytics. Assistance: Contact the Office of Academic Planning and Program Development at (936) 294-2291. *Hover over headers for additional information

University Curriculum Committee: Diversity and Inclusion Statement SAM HOUSTON STATE UNIVERSITY
4+1/3+2 (EXISTING PROGRAMS) CHANGE REQUEST FORM

Administrative Information (Existing Programs) Include administrative information for both the baccalaureate and master-level programs.
Baccalaureate Program Information	Master Program Information
1. Existing Program Name:
2. Program CIP Code:
3. Number of Required Semester Credit Hours (SCH):
4. Administrative Unit:
5. Location and Delivery Mode:
6. Contact Person: ☐ Contact person is the same for both programs	Name: Title: E-mail: Phone:	Name: Title: E-mail: Phone:

Administrative Information (Proposed 4+1/3+2 Program)
1. Proposed Program Name:
2. Number of Required Semester Credit Hours (SCH):
3. Administrative Unit for Proposed Program:
4. Location and Delivery Mode: Choose an item.
6. Proposed Implementation Date:
6. Contact Person: Name: Title: E-mail: Phone:

Program Description:

Purpose:

Transition Plan:

General Admission Criteria:

Please select the appropriate field below:

☐ Proposed 4+1/3+2 program meets minimum SCH requirements for both undergraduate and graduate degrees as designated by degree requirements.

☐ Proposed 4+1/3+2 program does not meet minimum SCH requirements for either/both undergraduate and graduate degrees as designated by degree requirements.

Justification:

Justification for proposed 4+1/3+2 program:

Curriculum:

Description of course sequencing:

Curriculum Information

Prefix and Number	Course Title	SCH
Degree Specific Requirement
Major: Foundation
Major: Prescribed Electives
Electives: General
4+1 or 3+1 Master of Science/Art in TITLE
Thesis
OR
Project + Internship
TOTAL

Required Appendices:

Copy of current Undergraduate Degree Program

Copy of current Graduate Degree Program

Program Approvals

Approved by Department Head/Faculty	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.
Approved by Department Chair	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.
Approved by Department CC (Optional)	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.
Approved by College CC (Optional)	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.
Approved by Academic Dean	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.
Approved by Director of APPD	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.
Approved by Provost	Approved	☐	Disapproved	☐
Signature: Click or tap here to enter signature.	Date: Click or tap here to enter date.

CC = Curriculum Committee
APPD = Academic Planning and Program Development

Added to Catalog ☐

Date: Click or tap here to enter date.

Added to Banner, if applicable ☐

Date: Click or tap here to enter date.

Added to Degree Works ☐

Date: Click or tap here to enter date.

Notified Advising ☐

Date: Click or tap here to enter text.

Added to Apply Texas, if applicable ☐

Date: Click or tap here to enter date.