FMPH 498 MPH Independent Study Course Request Form

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Please complete the questions below to request an independent study course. Your replies to these questions will populate a form that will be emailed to you in PDF format. Once you receive this PDF, gather the required signature from the instructor (electronic signatures permitted). Submit the completed and signed form to the MPH Program Coordinators (mphinfo@health.ucsd.edu) for processing. A Course Section ID code will be requested from the Registrar's Office. Allow 72 hours for this course to be created and posted in the Schedule of Classes. Once received, this information will be sent to the email address that you provided in the form. Grading Method is Satisfactory/Unsatisfactory Only. As a reminder 1 unit = 1 hr face to face & 2 hrs outside work. If you have further questions, contact the MPH Program Coordinators.

Student Name *

Please type your first and last name.

Student Email *

Please type your email address. Note this will be where the PDF form will be sent.

PID *

Please type your UCSD Student PID #.

Concentration *

Which concentration are you in?

Term *

Please click on the term below

ISP Faculty Mentor

Please list the following information about who you will be conducting your Independent Study session with.

Faculty Instructor Name *

Please first and last name of faculty member.

Faculty Instructor's Department *

Please select from the below list which department the faculty member is from. Remember to select the Department, not the Division. Do not type in Epidemiology or Global Public Health.

Family Medicine and Public Health

Medicine

Other:

Information on ISP Request

Please complete the following sections regarding information about your independent study request.

How many units? *

1 unit = 1 hr face to face & 2 hrs outside work

1 unit

2 units

3 units

4 units

5 units

6 units

What type of Independent Study will you be doing? *

Select from the following the type of independent study. If not listed, please type in the section under "Other". Select a max of 4 types.

Data collection

Develop a new method or tool (e.g. apply a new statistical method, develop a new instrument)

Literature Review

Develop a new manuscript

Develop a portion of a of manuscript (e.g. method, results)

Conduct Data Analysis (e.g. learn new skill; demonstrate analytic method)

Develop Human Subjects/IRB Protocol (e.g. draft documentation for IRB review)

Grant proposal process (e.g. develop grant design, rationale, protocol development)

Other:

Required

Description of course content/purpose. *

Please write a description of what you will be doing for this ISP. Include specific detail. Max characters: 750.

What type of deliverables will there be from this Independent Study? *

Select from the list of common student deliverables. If not listed, please type in the section under "Other".

Written section of manuscript

A complete draft of a manuscript

Written response to review comments

A detailed analysis plan

Written questionnaire

Set of tables and figures for manuscript

Submission of IRB Protocol

Written literature review

Detailed report on review or finding

Other:

Required

Student Deliverables *

List what the student deliverables will be. Include specific detail. Max characters: 750.

Submit

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