Extramural Request

EXTRAMURAL ELECTIVE, ACTING INTERNSHIP OR INDEPENDENT STUDY REQUEST

2024-2025 Academic Year
Student Name*

FirstMiddleLast
Student Email*
firstname.lastname@uscmed.sc.edu
USCSOM Rotation Dates (Select one)*
Request Type (Select one)*
Choose Elective Course (Select one)*
Choose AI Course (Select one)*
Host Course Title*
Host Course Rotation Dates *
Note: It could be different from USC SOM Columbia rotation dates
Host Course Description*
Host Institution Name and Mailing Address*
Host Contact Name and Title*
Host Contact Email/Phone Number*
Please enter an email address and/or phone number
Permission/Confirmation from Host Institution*

Please upload the confirmation (usually an email) from the Host Institution.
Cancelof
Once submitted and reviewed, the rotation will be processed and approved by the University of South Carolina School of Medicine Columbia.
Host Institution Name
Host Contact E-mail
example@example.com
Host Contact Phone Number
Should be Empty:

EXTRAMURAL ELECTIVE, ACTING INTERNSHIP OR INDEPENDENT STUDY REQUEST