Michigan State University - Application for Independent Study

Please Read the guidelines before completing this form. All Items must be completed before approval signatures are obtained.
Please type or print
Name_______________________________________________ Date_______________
              Last               First               Middle Inital
PID__________________ Level______ Class______ Major______________ GPA______
Course Alpha code and #___________ Section #_____ Credits_____ Semester_________ 20___
Number of other Independent Study
credits to be earned the same semester______		 Total of prior Independent Study
credits in semester credit equivalents______
  1. Description (Subject matter, purpose, methods)
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
  2. Rationale (Why independent study rather than regular course?)
    _________________________________________________________________________
    _________________________________________________________________________
  3. Preparation (Relevant course work, reading, work experience, etc.)
    _________________________________________________________________________
    _________________________________________________________________________
  4. Work to be completed (a) Type and amount of reading, writing, labwork, etc.
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
(b) Estimated contact hours per week with instructor________ (c)Deadline for submitting work for final evaluation________
(b) Evaluation procedure
___________________________________________________________________________ Student Signature_______________________________________ Phone_________________
Approvals
_____________________/_______
Instructor                                                           Date   _____________________/_______
Academic Advisor                                               Date _____________________________________________________/_______
Chairperson, Department Offering Course                                                                                                                       Date Distribution (By Department Offering Course)
Chariperson, Department Offering Course
Student
Instructor   Photocopies should be sent, per College preference, to:
Assistant Dean, Student's College
Advisor MSU is an Affirmative Action/Equal Opportunity Institution