Date of Application:
Application Submitted By:
Campus Telephone #:
Title of Experience:
Please select the best category under which the experience falls:
Typical Term(s) the Experience Takes Place:
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.
Did the requirements to complete this experience exceed the requirements to complete the course?
If yes, please explain:
Did the experience result in a special achievement, certification, or recognition that is not reflected on the academic transcript?
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:
Campus Telephone #:
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:
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:
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?:
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):
Do not fill in the following field