Sample Independent Study Request Form

Original form obtained through faculty adviser’s department office

  1. Status: Graduate Student ___ Undergraduate Student ___
  2. Proposed semester: Year ___ Fall ___ Spring ___ Sum I ___ Sum II ___
    1. Students, together with the faculty member supervising Independent Study, must have this approval form processed through the steps listed in section E prior to the end of the late registration process.
  3. Student Information
    1. Social Security number:
    2. Student name:
    3. Student’s mailing address:
  4. Rationale and Plan of Study (sample proposal): In conjunction with a faculty member, prepare an independent study proposal to be attached to this form. The proposal must include:
    1. a rationale for conducting an independent study
    2. the purpose of the study
    3. objectives
    4. activities to accomplish objectives
    5. required reading and/or a bibliography
    6. an evaluation process*
    7. use for special purpose, i.e., liberal studies elective, writing intensive, Honors College, non-western, etc.
    8. number of credits** 
  5. Signature Approvals and Verification:
    1. Faculty Member of Record: (This is the faculty member with whom you will be doing your independent study and who will be grading you.)
    2. Faculty Adviser:
    3. Chairperson: (of the department of the faculty member you will be working with)
    4. College Dean: (again, of your faculty member’s college)
    5. Registrar:

* It is a good idea to give yourself many opportunities to be evaluated rather than stake your whole grade on a single paper or project.

** No student may take more than six credits of Independent Study.