PHSC389 Request Form: Research Independent Study 
To enroll in PHSC 389, complete this request form with as much detail as possible. This serves as the formal request to use an independent study/research experience to count as academic credit. 

Approval requires you to provide information related to these 3 areas:
-Part 1: Student Information
-Part 2: Research Study & Mentor Information
-Part 3: Description of Research & Tasks

**We strongly recommend filling out this form with your research supervisor.

Submissions are due by the deadline indicated:
-Fall deadline: August 15
-Spring deadline: January 15
-Summer deadline: May 15
Email *
Part 1: Student Information
Student Eligibility Verification
Which semester are you requesting for? *
What major/program of study are you enrolled in? *
Enrollment in PHSC389 is restricted to UMD students in the PHSC major. For students outside the major, please speak with your program of study to explore options to receive credit for experiences outside of the classroom. 
Your full name *
UID # *
Email Address *
Phone # *
Part 2: Research Study & Mentor Information
Verification of fit of the research experience and mentor availability
Lab/Study Name *
ie Center for Young Adult Health & Development
Lab/Study Website *
Who is the hosting entity? *
Research Mentor Name *
Research Mentor Email Address *
PHSC administrators will contact them as part of the verification & approval process. 
Research Mentor Phone Number *
Research Mentor Job Title *
Mentor credentials (ie MPH, MSW, MD, PhD, etc...) *
Provide any relevant info on who will be your primary point of contact for this experience. Will that be a UMD faculty member? A graduate level assistant? Other?
What is the proposed work format? *
What is the supervisory arrangement?  *
Describe how you and the supervisor plan to stay in communication throughout the semester, particularly if this will be remote work. Weekly check-in meetings are strongly recommended.
Is there financial compensation for this research experience? *
How many credits would you like to register for? *
NOTE: You can earn up to 6 credits of PHSC 389 to apply towards your degree. 
The number of credits earned is directly linked to the number of work hours completed.
  • 1 credit = 45 total work hours
  • 2 credits = 90 total work hours
  • 3 credits = 135 total work hours
  • 4 credits = 180 total work hours
  • 5 credits = 225 total work hours
  • 6 credits = 270 or more total work hours
What is your proposed weekly schedule?  *
Indicate weekly start and end times, as well as any proposed weekend, evening, or special events.
Semesters are approximately 15 weeks, so you will want to map out your time accordingly. Your proposed weekly schedule should reflect the accurate minimum number of hours required. Consider holidays and UMD closings. 
Are there any special requirements from the research lab site that you need to fulfill before your start date (ie clearance forms, security check, medical requirements, affiliation agreements, etc)? 
If “yes,” please explain at the bottom of the form.
 *
Part 3: Description of Research Study & Tasks
Verification of the study, its fit within public health and PHSC learning outcomes, as well as appropriateness of student tasks and contributions.
Provide summary of your proposed research experience. Include specifics and important details that we should know about how you will be spending your time. Consider the skills, exposures and experiences that you may gain from this opportunity.

Special Considerations: If you are continuing with the same laboratory project two consecutive semesters, please use this space to clearly outline how this experience will be different this second time. You must outline increased responsibility, new project contributions, and a few new tasks in order to receive credit again.
 *
Which of the "Public Health Science Core Competencies" for your major do you aim to meet through this research experience? *
You can pick more than one, but not all.
Required
Describe the main objective of this research. What the question, hypothesis, or problem you are trying to solve? How will your duties contribute to the overall goals of the study? *
What is the significance of your research in terms of practical applications and its contribution to our understanding of today's top public health issues?
*
Describe the methods you will use to achieve the research objectives. What scientific methodology, resources, systems and data analysis tools will you use in order to successfully complete your tasks?
*
What are your career goals? And how do you see this experiences as a stepping stone in this direction?  *
Is there any additional information that you want us to consider for this request?
Please e-sign your full name below indicating that you agree to the following terms: 
-This form is filled out with accurate information to the best of your ability.
-That submission of this request form does not guarantee approval nor enrollment into the course.
-The supervisor is in agreement on the potential projects and tasks listed. 
-You permit us to contact the listed mentor supervisor to verify administrative details. 
 *
A copy of your responses will be emailed to .
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of Maryland, College Park. Report Abuse
Google Forms