School of Public Affairs
PETITION FOR INDEPENDENT STUDY (attach additional pages as necessary)
Prior to registration complete this form and obtain signatures of approval.
Name:___________________________________________________ UCCS ID# __________________________________
Program:________________________________________________________
Project Title:___________________________________________________________________________________________________
Number of Credits/Units: (usually 1-3)_____ (see note on federal credit hour definition on reverse)
Will be completed (check one) ☐Intersession
☐Spring ☐Summer ☐Fall Year:__________
Description of Proposed Study (completed by student):
Description of materials, resources, and methods (completed by student):
☐IRB is required for this project
(Check if applicable and see note on reverse. Research may not begin
until final IRB approval is obtained)
Brief Syllabus including deliverables (Completed by student, attach additional pages as necessary):
Method of Evaluation (completed by faculty supervisor, attach additional pages as necessary):
Meeting Dates with Faculty: 1_____________ 2_______________ 3______________ 4______________
________________________________________________________ ____________________________________
Student signature
Date
Approved_______
Denied__________
________________________________________________________________________
Approved________
Denied____________
________________________________________________________________________
Faculty Supervisor (Please print and sign your name)
Program Director (Please print and sign your name)
A note on Federal Credit Hour definitions: A credit hour is an amount of work represented in
intended learning outcomes and verified by evidence of student achievement that approximates
not less than one hour of classroom or direct faculty instruction and a minimum of two hours of
out-of- class student work each week for approximately fifteen weeks for one semester hour of
credit, or ten to twelve weeks for one quarter hour of credit, or the equivalent amount of work
over a different amount of time. 34CFR 600.2 (111112010)
Credit Hours
Total Student Work Hours
1
2
3
each additional credit hour
45
90
135
+45 student work hours
A Note on human subjects research: If the independent study includes research involving
human subjects, the University of Colorado Colorado Springs Institutional Review Board (IRB)
policies and procedures apply. For more information, direct your browser to:
http://www.uccs.edu/osp/research-compliance/research-involving-human-subject-irb.html
Any plans to conduct human subjects research must be addressed in this petition. Students are
not permitted to begin research projects involving human subjects until final IRB approval
is obtained.