Extramural Request

EXTRAMURAL ELECTIVE, ACTING INTERNSHIP OR INDEPENDENT STUDY REQUEST
Student Name *

First Middle Last
USCSOM Rotation Date (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 *
Host Institution Mailing Address *
Host Contact Person and Title *
Host Contact E-mail *
example@example.com
Host Contact Phone Number
Permission/Confirmation from Host Institution *

Please upload the confirmation (usually an email) from the Host Institution.
Cancel of
Once submitted and reviewed, the rotation will be processed and approved by the University of South Carolina School of Medicine Columbia.
Should be Empty:

EXTRAMURAL ELECTIVE, ACTING INTERNSHIP OR INDEPENDENT STUDY REQUEST