Copies: Bursar; Registrar; Institutional Research; J Caputo; 7/2015
Application for: Off-Campus _____ Workshop _____ Flexibly Scheduled Course _____
(All information must be completed by the instructor* conducting the course/workshop)
Semester offered: Fall ____ Summer ____ Spring ______
Year Offered ___________________
Course Title ______________________________________________
Department Name ______________________________
CRN ____________________ Course __________________
Field Site: YSU _____ or Name/Address/Zip Code of Off-Campus Site
(if various sites are used, please list primary site) ____________________
Starting Date _____________ Ending Date ____________________
Semester Hours ___________ Workload Hours _____________
Meeting Days and Hours___________________________________
Instructor(s) Name(s) _____________________________________
Phone Ext._________ Banner # Y00 ___________________
Total Number of Scheduled Contact Hours ___________________
# of Students Expected _______________
Amount of Outside Effort expected from student through
Little or none _________
Moderate _________
Significant _________
Identify prerequisites for the course (including department name and course number for prerequisite course(s) and other prerequisites, such as permission of
instructor, student rank, prior admission to a college or major, etc.):
Workshop Topic and Course Description: ___________________________________________________________
If a contract has been signed by an Authorized Institutional Official for this course (i.e. held off campus and the cost of instruction will be paid by an external agency,
grant, etc.), please indicate the fee the student is to be charged. If the course is funded by an external agency (i.e. grant, etc.), please provide the account number. If
the course is being paid by an external agency, please indicate the procedure for payment (i.e. billing, purchase order, etc.).
Please indicate exactly which fees are being paid by the external agency:
Application Fee _______ Non-Resident Surcharge _______ Instructional Fee _______ General Fee _______ Multi-Service Fee _______
Academic Computing Fee _______ Additional Fees (please specify) _______________________________________________
Refer to the Ohio Board of Regents Standards for Off-Campus Instruction Activity, Section C, RG 1-08; Ohio Board of Regents Operating Manual for Two-
Year Campus Program, Academic Credit, Page 600.1. Students enrolled in a graduate course who have not previously been admitted to the YSU Graduate
School may be registered as “Non-Degree Graduate Students.” All students, however, will complete a “Workshop Application” form.
ATTACH COURSE SYLLABUS (including, for example, reading assignments, writing assignments, examination date, self-paced or directed laboratory work, grading
policy, etc.)
*For Graduate Course Only: Students enrolled in workshops are graded on a S/U basis. Instructor must have current Graduate Faculty Status. If not, required
paperwork must be completed before the course/workshop is offered.
Signature of the chairperson and dean below attests to the accuracy of the information submitted above and that excess course costs not covered above will be
the responsibility of the department and college. The college dean approves the workshop tuition rate.
Chairperson & Date
College Dean & Date
Graduate Courses Approved By:
OBOR Course Number
Workshop Tuition Rate Approved: Yes_____ No_____
Graduate Dean & Date
Associate Provost & Date