Revised 8/1/07
CHADRON STATE COLLEGE
Request for Independent Study
(This form must be completed prior to enrolling in an independent study course)
Name
Student ID Number
Course Prefix and #
Term Credit Hours
IS: Instructor:
Title to appear on student transcript
(Maximum of 20 characters, including spaces) Completion Date
Please attach to this sheet the reason for this independent study and the detailed requirements,
including activities, timeline, and grading process.
Agreements:
I agree to the learning activities, the timeline, and the manner in which the course will be graded.
Signature of Student Date
This is the binding agreement for the course as agreed upon by the student and the instructor.
Signature of Instructor Date
Approval:
Signifying approval to offer course and that Dean has the necessary resources to handle the independent
study.
Signature of Academic Dean Date
Signifying the policies of the institution are upheld and that the expense can be justified.
Signature of Vice President for Academic Affairs Date
Original copy to: Registrar’s Office
Keep copies: Dean, Instructor, Student
Approval for payment at course conclusion:
Signifies a grade has been posted for this course, and sends completed form to the Human Resources
Office for processing.
Signature of Academic Dean Date
