Experiential Learning Program Form

This form should be completed by departments proposing a new or renewed program of extra-curricular experiential learning for UM students or non-UM participants, including high school students.

Please direct questions to studentprograms@olemiss.edu.

Request Type*

Is this a new request, or a renewal request for a previously approved program?

New Request

Renewal

Program Basics

Program Name*

For renewal requests, please select your program from the drop-down list.

For new program requests, please enter your program name.

Select or enter value

Program Director Name*

Director Email*

Other Contact (if any)

Other Contact Email

Requesting Department*

Type of Program*

In Person

Virtual

Program Start Date*

Program End Date*

Hours a Day*

How much time per day will each participating student be expected to spend on program activities?

Select

Consecutive or Intermittently?*

Will participants attend the program on consecutive dates or intermittently?

Consecutive Dates

Intermittently

Provide details about participation dates/times:*

Provide the program website (if any):

Participant Information

Provide below the anticipated number of participants.

High School Students:*

UM Undergraduate Students:*

UM Graduate Students:*

Other/External Participants:*

TOTAL Number of Participants:*

Renewal Information

Last Offered*

What was the last year this program was offered?

Program Number*

What was the approved Program Number that year?

Changes to the Program*

Have any changes been made to the program since last approved?

Yes

What changed (select all that apply):*

purpose of the program

activities in which participants will be involved

recruitment and selection process

whether the host department receives an immediate advantage from participant activities

benefits that participants receive from the experience

expectations placed on participants

direct correlation between the participant's field of study and the program experience

other

Provide details of how the program is different.*

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Program Information

Purpose*

Describe the purpose of the program.

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Activities*

Describe activities in which the participants will be involved.

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Recruitment and Selection*

Describe the process by which participants will be recruited and selected (in compliance with UM's EORC Statement https://eorc.olemiss.edu/).

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Program Criteria

Immediate Advantage*

Does the host department receive an immediate advantage from the activities of the participants?

Yes

Please describe the advantage:*

The answer to this question will help the Student Experiential Learning Program Review Board determine whether program participation could actually create an employer/employee relationship between UM and the participant.

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Participant Benefits*

Provide a brief description of the benefits (beyond any compensation) that participants will receive from this experience.

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Expectations*

What expectations are placed on the participants?

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Field of Study Related*

Is this experience directly related to the participants' field of study?

Yes

Do all participants receive the same experience?*

Yes

Please describe how the experience will vary:*

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Additional Information

Please share any additional information pertinent to this request.

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Financial Information

Payments*

Will or might you provide any payments to program participants?

Yes

How much will each participant receive?*

Enter numbers only.

Will ALL participants receive payments?*

Yes

Why won't all receive stipends?*

Why won't all participants receive stipends and how will the decisions be made about who gets paid?

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Will ALL participants be paid the same amount?*

Yes

Why won't all be paid the same?*

Why won't all participants be paid the same amount and how will decisions be made about who receives how much?

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What is the purpose of the stipend?*

To defray travel expenses.

To defray lodging expenses.

For meals during the experience.

As an incentive to participate.

As payment for service rendered.

If we did not pay them, we would need to pay someone else to do these activities.

Other

"Other" explanation. *

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Will any participant be paid IN ADVANCE?*

NOTE: Advanced payments of participant stipends are generally discouraged but may be considered in extraordinary (rare) circumstances. Advances for actual travel experiences are the generally preferred way to pay advances.

Yes

Advanced Stipend Information*

Explain how much is requested to be paid in advance, by when, and why.

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What classification of students may participate?*

UM Undergraduate students who are NOT enrolled in classes for credit during the experience (complete Form 7 if participant payment is involved)

UM Graduate students who are NOT enrolled in classes for credit during the experience (complete Form 7 if participant payment is involved)

UM Undergraduate students who ARE enrolled in classes for credit during the experience (Financial Aid will review)

UM Graduate students who ARE enrolled in classes for credit during the experience (Financial Aid will review)

High School students concurrently enrolled in UM classes (complete Form 7 if participant payment is involved)

High School students not enrolled in UM classes (complete Form 13 if participant payment is involved)

Individuals who are NOT UM students (complete Form 13 if participant payment is involved)

Participants are Enrolled - UM Students*

You indicated participants are either UM Undergraduate or Graduate students who ARE enrolled in classes during the experience. Is the academic credit for the experience or other courses not directly related to this experience?

Briefly explain known plans for academic credit (course numbers, etc.).

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Participants are Enrolled - High School Students*

You indicated participants are High School students concurrently enrolled in UM classes. Briefly explain plans for academic credit. (High School students must meet the Early Admission requirements to be enrolled in UM courses. LIBA 103 and BIO 100 are options for the research experience).

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Has funding already been secured for this program?*

Yes

Provide the funding source(s), if known.*

Account number and name/description.

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Are you currently seeking funding?*

Yes

Briefly describe your plans.*

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Grant Funded*

Will this program be funded by an intended, pending, or awarded grant?

Yes

Sponsor Guidelines*

Has the sponsor provided guidelines for whether or how the participants should or may be paid for the experience, or for what expenses can be paid by the host institution on the participant's behalf?

Yes

Cite the sponsor and program name for review.*

Cite the sponsor and program name for review, and provide a URL(s) where these guidelines can be found. If possible, excerpt the sponsor's guidance here.

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Payments to Other Parties*

Will any funds be paid to OTHER PARTIES (e.g., to Outreach or other university units for lodging, meal plans, etc.) on behalf of, or for services benefiting, the participants?

Yes

List and explain all such payments:*

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Information for Programs Involving Minors

Minors as Participants*

Will or might minors participate in this program?

Yes

Program Times*

Please list all program times (days of week and times of day) when minors will be involved in this experience (under the supervision of the Director).

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Site(s) of Experience*

Please list the building name(s), room number(s), laboratory(ies), or other locations where these supervised experiences will occur during these program times.

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Time/Activity Time Allocation*

Provide the following percentages:

Percent of time in supervised lab experience.
Percent of time in supervised field experience.
Percent of time in non-lab/non-field activities.

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Explain all non-lab/field activities (if any):

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Health, Safety, Compliance & Risk Management Plan

Before working in any lab or field environment that poses risks to health or safety, all minors will be required to satisfactorily complete health and safety training appropriate for their research, as described below. The Chair of the department hosting the research experience will ensure that the Faculty Mentor, Assistant Mentors (if any), and all participants, adhere to all applicable Health and Safety regulations/standards as defined by a set of university policies identified by the ARISE@UM Supervisory Board, including:

the Biological Safety Manual Policy (#10000299)
the Chemical Safety Manual Policy (#10000302)
the Radiological Safety Manual Policy (#10000289)
UM’s IACUC policies

Biological Safety: Persons under 18 years of age will not be allowed to enter a Biosafety Level 3 (BSL3) laboratory (currently, there are no BSL3 labs on the Oxford Main Campus).

Radiological Safety: Persons under 18 years of age will not be allowed to enter, or work in, an area where radioactive materials or radiation-producing devices are used, stored, or operated.

Chemical Safety: Minors under 16 years of age will not be allowed to enter, or work in, an area where hazardous materials are used or stored.

Animal Research Areas: Minors under 16 years of age are not allowed in animal care facilities.

Institutional Animal Care and Use Committee (IACUC) Requirements: Before engaging in any activity involving live vertebrate animals, participants must meet all training and occupational health requirements and be granted UM-IACUC approval.

Please note that all minors will not be permitted to perform any experiments without direct supervision. If you have questions regarding the safety training, contact UM’s Department of Health & Safety at 662-915-5433 or visit their website.

Approval and Training*

The Chair of the host department will ensure that minors and his/her Mentor Team receive approval and training in the following areas before entering the labs/field environments for their research (select all that apply):

Animal (IACUC Approval):*

Describe efforts to minimize risks.

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*Or upload a document describing the efforts to minimize risks.

Biological Safety*

Describe efforts to minimize risk.

*Please keep text within box provided. Meaning, text should not scroll.

*Or upload a document describing the efforts to minimize risks.

Chemical Safety*

Describe efforts to minimize risks.

*Please keep text within box provided. Meaning, text should not scroll.

*Or upload a document describing the efforts to minimize risks.

Radiological Safety*

Describe efforts to minimize risks.

*Please keep text within box provided. Meaning, text should not scroll.

*Or upload a document describing the efforts to minimize risks.

Other:*

Describe "Other" and efforts to minimize risks.

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*Or upload a document describing the efforts to minimize risks.

Research Supervision Plan

There will be several components to the summer research experience:

Reading*

The Mentor will choose research and technical articles for participants to read to introduce the background and methodologies behind the research in the laboratory.

THE MENTOR SHOULD ADD ANOTHER SENTENCE HERE SPECIFIC TO THE PARTICIPANT’S EXPERIENCE.

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Individual Meetings*

The Mentor will meet with participants formally every week on a WEEKDAY to discuss the research project.

THE MENTOR SHOULD ADD ANOTHER SENTENCE HERE OR CUSTOMIZE THE LANGUAGE ABOVE SPECIFIC TO THE PARTICIPANT’S EXPERIENCE.

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Research*

Participants will work closely with the Mentor and Assistant Mentor(s) listed above.

DETAILS TO BE PROVIDED BY THE MENTOR HERE.

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Supervision of Minors Plan:

At all times in the research lab or field site location, Mentors and the Chairs of the Host Departments will be responsible for ensuring participating minors are supervised in compliance with the University of Mississippi’s Protection of Minors Policy (#10000843).

Supervision Details*

Explain how participating minors will be supervised during lab times. Provide details that outline how mentors will ensure that no one-on-one contact occurs between participating minors and persons over the age of 18 years of age.

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Residential Support for Minors*

Will the participating minors need residential support?

If YES, contact the Office of Pre-College Programs (662-915-7621) regarding scheduling and required documents.

Yes

Additional Information (Supervision of Minors)

Please share any additional information pertinent to this request.

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Document Upload

REQUIRED FOR RENEWALS: Upload a copy of your program report from the previous year as well as a list of program participants. Refer to the prior year's approval email/letter for details.

OPTIONAL: Upload additional documents to provide information on budget or details on risk management plans if needed. If used, please reference in appropriate text box.

Drag and drop files here or

Acknowledgement/Authorization

I acknowledge that the information provided on this form is accurate to the best of my knowledge and understand that this form and supplemental documentation, if requested, will be assessed by the Student Experiential Learning Program Review Committee to determine whether an employment relationship exists for any proposed participant payments, and/or by a Rebel Research Scholars Advisory Board to make recommendations regarding the program and supervision of minors in a research environment. I understand that to knowingly provide misinformation in an effort to be awarded an affirmative determination may result in the denial of future program requests. The appropriate determination(s) and/or recommendations will be sent to the Program Director and/or Other Contact via email.

An email will be sent to the Program Director confirming receipt of the request form.

Acknowledgement (Program Director)*

Department Head/Chair Name*

Department Head/Chair Email*

Send me a copy of my responses

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