Student Experience Enrollment - Prisma Health Academics

This form should only be used by students that have received approval from a Prisma Health Host to participate in a pre-existing or pre-approved experience.

This form should only be submitted by students that have received the Principal Investigators’ or Faculty’s approval to participate in the research experience.

This form should NOT be completed by UofSC medical students in the MD program.

CLEARANCE TYPE

Are you primarily *

participating in a Prisma Health and/or university research experience?

interning independent of a university course?

participating in a university course that will include interning or experiential learning within Prisma Health?

Will you be on any Prisma Health property during your experience? *

Yes (On-Site)

No (Virtual)

Will you come into contact with patients during your experience? *

Yes (Clinical Environment)

No (Non-Clinical Environment)

Will you require access to patient or hospital related data? *

Yes

* You’ve indicated you will not be on a Prisma Health property, that you will not be in contact with patients and that you would not need access to patient or hospital related data. Please confirm with your Prisma Health host that you need to be cleared through Prisma Student Affairs. *

STUDENT INFORMATION

College/University * College/University

Are you an MD student enrolled at the USCSOM Columbia or Greenville? *

Yes

Please enter your academic program name.

Please discontinue progress on this form.

If you are a USCSOM Columbia MD student, please contact Dr. Eric Williams at eric.williams@uscmed.sc.edu.

If you are a USCSOM Greenville MD student, please contact Renee Chosed at chosed@greenvillemed.sc.edu.

If you will require additional software accesses (i.e., RedCap or Cerner), please email Student.Affairs@PrismaHealth.org. All medical students are automatically granted Epic access at the beginning of the academic year. Please view the onboarding website for information on Epic: https://academics.prismahealth.org/som.

Are you in the Clemson Nursing Program? *

Yes

Please indicate if any of the following apply:

I’m enrolled in a Clemson Bio-E Senior Design Course (BIOE 4010, BIOE 4030)

I’m participating in the REEP EM Research Program

I’m participating in the CURES Surgery Program

First Name *

Middle Initial *

Last Name *

Preferred Name

Please check if you are a returning student and have a (existing or expired) myClinicalExchange account

Yes – I have participated in Prisma Health Internships, Research, Observations, etc.

Please enter the email address that you previously used to log into myClinicalExchange. Using the email address associated with your myClinicalExchange account allows your previously submitted clearance documentation to cascade. This includes your background check and immunization records.

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

Your Date of Birth and the last 5 digits of your Social Security Number are required by Prisma IS. Prisma IS will need these in order to assign any technology related request submitted by your Prisma host.

SS# – Last 5

Date of Birth

MM/DD/YY

Anticipated Start Date *

Anticipated End Date *

University Faculty Contact Name

University Faculty Contact Email Address

PRISMA HEALTH DEPARTMENT INFORMATION

There are approximately 1500 Prisma Health locations to select from. If you’re uncertain of the Facility, Department and Unit, please use the Search feature below. After searching and identifying the correct Facility, Department and Unit, please transfer this information in the corresponding fields below.

SEARCH – Region: Facility > Department > Unit *

Prisma Contact First Name *

Prisma Contact Last Name *

Prisma Contact Email *

Will this experience fall within a division of the Midlands Pediatric Department? *

Yes

Examples include: Peds Rheumatology, Peds Pulmonology, Peds Nephrology, Peds Urology, Peds Surgery, Peds Cardiology, Peds Neurology, Peds Heme/Onc, Peds Developmental, Peds Concussion/Sports Medicine, Peds Critical Care, General Peds (clinic and hospitalist), Peds Child Abuse, Peds Gastroenterology, Peds Endocrinology, Peds Rehab, Peds Infectious disease

EXPERIENCE

Please understand due to the nature of clearance and *clearance requirements, GHS Student Services can only clear students on an annual basis. If the student plans to be here multiple years, we would need to re-initiate clearance approximately 1 year from now. *TB, Flu and HealthStream assignments must be renewed annually. In order to ensure compliance, Student Services must re-initiate clearance.

Research Project Name *

PRO / IRB Number (if applicable)

Including an IRB Number will alert the GHS IRB of a new student participant. Please leave blank if there’s no associated IRB study.

Brief Synopsis of Research Project (or Abstract if available) *

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If you are human, leave this field blank.