Submit an Experience - Truman State University

Date of Application:

Application Submitted By:

Name:

Title:

Campus Telephone #:

Campus Address:

Campus E-mail:

Title of Experience:

Please select the best category under which the experience falls:

Title of Experience:

Typical Term(s) the Experience Takes Place:

Fall

Spring

Summer

Brief Description of the Experience:

Which Quadrant best describes the outcome of this experience?

Please provide a brief rationale for your choice of Quadrant:

Do students receive academic credit for this experience?: (If the experience includes the awarding of academic credit, approval from the appropriate academic dean is required for the experience to be listed on the Cocurricular Record).

If no, go to item 17.

Yes

No

Did the requirements to complete this experience exceed the requirements to complete the course?

Yes

No

If yes, please explain:

Did the experience result in a special achievement, certification, or recognition that is not reflected on the academic transcript?

Yes

No

If yes, please explain:

Approximately how many hours do students devote to this experience? If academic credit is awarded, list how many hours students devote to this experience beyond what is required for the course:

Please list approved supervisors for this experience:

Name:

Campus Telephone #:

Campus Address:

Campus E-mail:

If approved supervisors are not members of the Truman faculty or staff (or you have more than one Truman supervisor), please provide the following information:

Name:

Telephone #:

E-mail:

Address:

Organization:

Title:

Qualifications:

Describe how the experience contributed meaningfully to an academic field of study or to the development of the student's professional skill and competence:

Please check up to five university or departmental learning outcomes to which this experience contributes:

Ask questions and passionately seek knowledge

Strive for personal integrity and professional excellence

Demonstrate courageous, visionary, and service-oriented leadership

Act ethically, responsibly, and with reflective judgment

Appreciate ambiguity and thrive in unfamiliar, rapidly changing situations

Understand and articulate well-reasoned arguments

Welcome and value new and diverse perspectives

Live emotionally and physically healthy lives

Give generously of their time, talents, and financial resources to causes in which they believe

Other learning outcomes not included in the above list: (Some applications for inclusion listing general education and departmental learning outcomes will require approval from the appropriate academic dean prior to inclusion of an experience as a part of the Cocurricular Record.)

Describe the opportunities that students are given to reflect upon what they are learning or have learned about this experience:

Describe the opportunities in which the student receives feedback regarding his/her performance:

Does the student have an opportunity to provide feedback regarding the quality of the experience?:

Yes

No

Please explain:

Approximately how many students per year complete this experience?:

If there is additional data that you would like to collect regarding this experience, please describe the data below:

When and by whom will the names, Banner numbers, and other desired data about students completing this experience be submitted? (spreadsheet template will be provided upon approval):

When:

By Whom:

Title:

Telephone #:

Campus Address:

Campus E-mail: