Independent Study Template - University
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1INDEPENDENT STUDY
S TAT E U N I V E R S I T Y O F N E W Y O R K
Office of Records & Registration, SUNY New Paltz, 500 Hawk Drive, New Paltz, NY 12561-2439
Semester and year:
Fall
Winter
Spring
Summer
20_____
PLEASE ATTACH A CURRENT TRANSCRIPT TO THIS FORM.
The guidelines for independent study vary. Consult the appropriate faculty dean for further information.
N
__________________________________________________________________
Last Name
First
MI
Student ID Number
__________________________________________________________________
______________________________________
Local Address: Street
Apt. No.
E-mail
__________________________________________________________________
(________) ____________________________
City
State
Zip Code
Telephone Number
COURSE NO.
SECTION NO. ___________________
Check one:
(Assigned by Records & Registration.)
295 ______
Undergraduate level
__________________________
CREDITS _______________________
495 ______
Subject
LA
_________
_________
595 ______
Graduate level
__________________________
(yes)
(no)
Subject
795 ______
(
)
Assigned by Dean
A. Nature of Project:
Readings
Research
Assistantship
Other _________________________________________________________________________________
Explain Briefly
B. In an attached document, please describe your proposed study project. Type/print clearly. What is the proposed method of study?
Where appropriate include a list of readings, practical experience, and/or a description of your research design.
_____________________________________________________
Total credits registered _____________________________
Signature of Student
Date
(After addition of Independent Study)
C. To be completed by instructor: Please include the following information on an attached document.
1) Student learning outcomes
2) Topics to be covered
3) Reading materials and assignments
4) Schedule for quizzes, papers, and examinations with basis for mid-term evaluation
5) Explanation of course grading policies
6) Method of determining the final grade, including relative weight of each assignment
___________________________________________________
________________________________________________
Instructor Banner ID Number (REQUIRED)
Signature of Instructor
Date
___________________________________________________
Please PRINT Instructor’ s name
_____________________________________________________
________________________________________________
Signature of Department Chair
Date
Signature of Dean
Date
Dean approval for excess credit (if necessary)
Submit completely signed form to Records & Registration.
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