Instructions: Please complete all items and then PRINT this form (it is not an electronic form submission process). A syllabus and course description must accompany all forms. This form must contain all signatures.
| Campus: Brandywine Semester of Delivery: |
| Course Abbreviation/Number: Number of Credits: |
| Course Title: |
| Instructor Name: |
| Student is taking course for Honors credit: Yes | No (If yes, Honors Independent Study Form must be included.) |
Student Information:
| Student Name: Student Penn State ID : |
| Email Address: Phone: |
Course Information:
| Syllabus (including examination policy, basis of grade and academic integrity policy) must be attached; (required) |
| Course Description (approximately 200 words); attached (required) |
Signatures Required :
| Student: | Date: |
| Instructor: | Date: |
| Honors Adviser: (Needed if student is taking as an Honors course) |
Date: |
| Adviser: | Date: |
| Division Coordinator: | Date: |
| DAA: | Date: |
OFFICIAL USE ONLY - Instructor Compensation (to be completed by the DAA):
Not part of load, no extra compensation: (2 in ARUAI) Not part of load, extra compensation: (3 in ARUAI)
(08/03/17)