HL S: Independent Study/Readings Agreement

Undergraduate and Graduate Students

Independent Study/Readings Agreement

College of Health and Social Services
Department of Health Science

Student's Name

Course No.

Student's Social Security No.

Phone No.

Semester & Year in which course is to be completed:

Please list your cumulative Grade Point Average (if known):

Academic Major:

No. Course Credits Applied For:

Reason for Requesting to Complete an Independent Study

Note: Independent studies are not to be used as a substitute for a required course without approval of a course substitution/waiver form signed by your advisor, department head, and with the approval of the CHSS Dean's Office.

Requirements To Be Fulfilled:

Sample List of Readings

Specific Requirements, Projects, etc.

*Not necessarily inclusive

METHOD OF EVALUATION (be as specific as possible):

Signatures (required)}:

Student
Date

Instructor
Date

Advisor
Date

Academic Department Head
Date

Distribution: ____ Student's Departmental File ____ Instructor ____ CHSS Dean's Office Copy

Student's Name
Course No.
Student's Social Security No.
Phone No.
Semester & Year in which course is to be completed:
Please list your cumulative Grade Point Average (if known):
Academic Major:
No. Course Credits Applied For:

Student	Date
Instructor	Date
Advisor	Date
Academic Department Head	Date