FACULTY/INSTRUCTOR OR RECORD
Regular (tenure track or term) Faculty
Faculty/Instructor Printed Name ID
Facult
y/Instructor Signature Date
Dean or Designee Signature Date
Independent Study Checklist:
1. Determine course- Course must differ significantly from any catalog course and may not be duplicates of existing courses.
2. Obtain Instructor/Department Approval
a. Regular or term faculty member must sign Independent Study Form
b. Faculty member must provide a course syllabus explaining course objectives and how student will be graded.
3. Obtain College Dean’s Signature or (Designee
4. Student must hand deliver Independent Study, Course Syllabus & Schedule Change Forms to University Center.
5. Allow 3 days for processing (must submit minimally 1 week prior to deadline to register).
6. Understand that by submitting Independent Study, Course Syllabus & Schedule Change Forms to University Center, student will be registered for and
financially responsible for requested course.
Notes:
• It is the student’s responsibility to ensure all signatures are obtained and form is turned in to the University Center
• It is the student’s responsibility to ensure that they are registered for the course prior to registration deadlines and that tuition and fees have been paid.
• Retroactive registration is not permitted
• Cannot be used to fulfill GER—this policy is not petition able.
Students must keep all supporting documents for Independent Studies. This form will not be processed unless it is complete
with all signatures. Students are to bring their completed paperwork to the Enrollment Services Office, located in the
University Center, for processing.
SEMESTER SPRING _ _ SUMMER ____ FALL ____ Year ___ ________
Date _
Date _________________
Student ID _______________________
Email ________________________
__________________________________________________________________ _____________________________________
Name (printed) Last First Middle Phone Number
INDEPENDENT STUDY
OFFICE USE
I understand that if approved I will be registered for this course for the semester for which it’s built and assessed appropriate tuition fees.
____________________________________________________________________________ Date __________________
Student Signature
____________ Initials
Course Reference Number
__
____________
_______
INDEPENDENT STUDY
I request permission to register for an Independent Study. An Independent Study course is a course consisting of topics or problems chosen by the student with the approval
of the department concerned, with the supervision of an instructor, and final approval by the Dean/Director. These courses are not duplications of and must differ
significantly from any catalog course. (See Chapter 7 of UAA catalog for full definition and instructions)
The Independent Study being requested:
_________________ ____________ ____ _______________________ ________________________________________________________
Department Course # Title Credits
Grading: A-F ________ P/NP __ ___ ___
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