Fillable Southern State Community College - Independent Study Request Form

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Southern State Community College - Independent Study Request Form

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Revised 1.29.19
___ Student Course History
Independent Study Request Form
This application with documentation must be submitted no later than one week before the beginning of the semester. Do not
start on an Independent Study until you receive notice from the Records Office that it has been approved and you have been
automatically registered for the course. This type of study is limited to two per student per degree.
Student Name: ________________________________________________________________ ID#: _____________________ Date: _______________________
Email: __________________________________________________________________________ Phone/Contact #: ____________________________________
Semester/Year to be Scheduled:________________________ GPA:_________ Estimated Graduation (SEM/YR): ______________________
Course Number: _____________________________________________________ #Credit Hours: ________ Major: ________________________
Reason this course cannot be taken in a regularly scheduled classroom setting:
___ only course needed to graduate and it is not offered this semester
___ class cancelled because of low enrollment
___ matches student’s degree plan and is not offered regularly
Other___________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Progress meetings will be held on M T W Th F ____________________ weekly every 2 weeks
(Check ) (Time) (Check one)
Other arrangement for Progress meetings: _______________________________________________________________________________________________
The following documents must be attached: (Request forms submitted without documentation will be returned to student.)
___ Course Outline and/or Syllabus ___ Method of evaluation ___ Student G.P.A.
____
________________________________________________________ _______________________________________________________________
Student’s Signature Date Full Time Faculty Signature Date
____
________________________________________________________ _______________________________________________________________
Student Name (Printed) Full Time Faculty Name (Printed)
(Full
time faculty signature is needed _______________________________________________________________
when an Adjunct is teaching the class. Adjunct Faculty Signature Date
Each I.S. counts as one credit hour towards
24 hour yearly adjunct teaching limit.) _______________________________________________________________
Adjunct Faculty Name (Printed)
Office Use:
____Approved ____Not Approved
Reason not approved ____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
________________________________________________________________
Dean Date
**Top Page Only: Original goes to Records Dept. Copies to Angie Moots and Angie Devilbliss after approval.
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Southern State Community College - Independent Study Request Form

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Completed 4 May 2020

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