ITHACA COLLEGE School of Health Sciences and Human Performance Undergraduate Petition for Independent Study / Research / Readings (Note: this form must be filled in online, no handwritten forms will be accepted) Student Information Name: E-Mail: Major: I.D. Number: Telephone (Local/Cell): Minor: For office use only: Independent Study/Research/Readings Information Department: please choose one Course Title: Course Number: Number of Credits (check one): 1 Semester of Registration (check one): Dates of Study: Name of Faculty Sponsor: CRN:____________________ Registered ______ Date______ 2 Fall 3 Spring Summer Winter Planned Time Commitments (In the space below, please list the approximate number of hours that will be spent in each area. The total number of hours must sum to a minimum of 45 hours per credit) Reading: Research: Writing: Faculty Consultation: Exams: Lab: Other: (please explain): Total Hours Involved: Design Statement Students must complete a Design Statement and attach to this form. Please follow the format provided on page 2. The design statement must accompany this application when obtaining signatures. Signatures The student will be registered in the course by a staff member in the HSHP Dean’s office after all signatures have been obtained in this order. Student Approval Date Faculty Sponsor Approval Date Consultant (if any) Approval Date Student’s Faculty Advisor Approval Date Chair of Faculty’s Sponsor Department Approval Date HSHP Deans Office (Dean/Associate Dean) Approval Date Page 1 of 2 Required Components of the Design Statement for Independent Study / Research / Readings An independent study is based on a special arrangement between a student and a faculty sponsor. It allows specialized or individual kinds of study that may not be available in regular classroom or laboratory instruction. Eligible types of designs include categories such as independent study, directed study, advanced reading and independent research. The required design statement sets forth the specifics of the study arrangements as agreed to by the student and the faculty sponsor. The following component parts should be clearly stated: 1. Course Information: Course number as listed in the Undergraduate Catalog, the title of the course, student’s name and ID number, semester and year of registration for the course. 2. Amount of Credit: Independent research can be taken for 1 to 3 credits. The total amount of time a student should spend on activities directly involved in this study is determined based upon the formula that one credit hour represents 45 hours of student learning. 3. Learning Objectives: Specific description required. 4. Student Preparation: A description of the student's preparation for undertaking the study (e.g. previous coursework, etc.). 5. Reading List: A suggested or partial list of material sufficient to provide focus and stimulate investigation in the topic. 6. Research: A description of the forms and scope of the culminating activity of the research (e.g. written paper, final exam, presentation, film, etc.). 7. Methods: A description of the method and amount of on-going interaction with the faculty sponsor/consultant (e.g. meetings, periodic discussion of research, discussion of final product, methods of reporting progress, etc.). 8. Timeline: Describe weekly activities. 9. Grading Scheme: State the criteria and procedures for evaluation and the weight given to various elements of the study. Indicate if the final grade will be pass/fail or a letter grade. 10. Consultants (if any): Where the research involves more than one faculty member, one faculty member should serve as the faculty sponsor and the others as consultants. The role and contribution of each consultant should be included, but the overall responsibility for overseeing the course remains solely with the faculty sponsor. Page 2 of 2