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
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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.
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