INDEPENDENT STUDY PROJECT

(Psyc 299/399) 

Before enrolling in this Independent Study, discuss your responsibilities with your Faculty Mentor and/or your Day-to-Day Supervisor.  This discussion will supply the information needed to fill out the “Responsibilities” section below.  Complete the form including all specified signatures. 

Where the project will extend beyond one semester, please indicate that on this form.  You must get registered for each semester by the end of the “add” period.  Where a second semester is indicated, simply complete another form and resubmit it for approval. 

This is a                                        Psyc 299         [        ]            Psyc 399        [         ]   project

and will be conducted                    Spring 2006    [        ]            Fall 2006        [         ] 

Name (print):___________________________________________________________________________________________ 

e-mail:  _______________________________________________________________________________________________

Last 4 digits of S.S. #:  _______________________         Tel. No.: ________________________________________________ 

Faculty Mentor: _____________________________________________   e-mail:  ___________________________________ 

Day-to-day Supervisor:  _______________________________________   e-mail:  ___________________________________ 

Topic of Proposed Project:  _______________________________________________________________________________

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Student Responsibilities:  ________________________________________________________________________________

_____________________________________________________________________________________________________ 

_____________________________________________________________________________________________________ 

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Nature of Student’s Contact with Statistical Issues in the course of doing this project:  _______________________________

_____________________________________________________________________________________________________ 

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Student Signature:  _____________________________________________________________________________________

Faculty Mentor Signature:  ______________________________________________________________________________ 

Day-to-day Supervisor Signature:  _________________________________________________________________________
(if different from Faculty mentor)

Undergrad Chair Signature:  _____________________________________________________________________________