Independent Study Application Form
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1Registrar
INDEPENDENT STUDY APPLICATION
This application is not for FOS 402 course. Undergraduate independent study must have the
signature of the Department Chairperson. Office of Undergraduate Studies signature required for
undergraduate 400-level courses. Signature of Dean of Graduate Studies for Graduate students
required for all graduate independent study courses. Students registering for independent study
have until the end of the 2
week of class (1
week in summer session) to submit this application. No
nd
st
registration for independent study courses will be processed until this application is complete and
signed by all parties. No independent study is allowed during the winter session.
All fields must be completed by the Instructor
Part I: Student information:
First Name: __________________________
Last Name: _______________________
Last 4 digits of SS#: _______________
Email Address: __________________________
Telephone (home): (_____)_____________
Telephone (cell): (_____)______________
Part II: Course Information:
Discipline: ______________________________
Course Number: ______________
Course Title (
): __________________________
cannot be “Ind. Study” and no more than 16 characters
Semester (
): □ Fall
□ Spring
□ Summer 1
□ Summer 8 week
□ Summer 2 Year: ___
check one
□ Graduate
□ Undergraduate
Which degree program is the student pursuing?
Instructor’s Name: ____________________________________
Description of Course: _____________________________________________________
_____________________________________________________________________
Texts and other bibliographical resources to be used: ________________________________
_____________________________________________________________________
Student Assignments: _____________________________________________________
Number of hours* required in: Conference Meeting: _______ Schedule Conferences: _______
Supplementary Assignments: ______________
*
A semester Hour of credit requires a combined 45 hours of instruction and supplementary assignments.
Method(s) of evaluation (
): ______________________
must include oral presentation or written report
_____________________________________________________________________
Signatures by the student and instructor denotes acceptance of all requirements
detailed above.
Student Signature (required): ___________________________
Date: ___________
Instructor Signature (required): __________________________
Date: ___________
Dept. Chairperson (required): ___________________________
Date: ___________
Office of Undergraduate Studies
: ________________ Date: ______
(required for 400-level course)
Dean of Graduate Studies (
): ______________________ Date: ______
required for Grad Students
For Office Use Only
SIMS Process By: ___________________
Date: ___________________________
For Office Use Only
Fall _____
Winter _____
Spring _____
Summer ______
Rec’d By: _______________________
Date: ______________________
White – Registrar
Yellow – Faculty Member
Pink – Student
12/28/2012
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