Southern Illinois University School of Medicine

Southern Illinois University School of Medicine - Community Service


Community Service Project Approval Request

Thank you in advance for your submission. We ask that fill out this form as completely as possible. Most fields are required. If we have any follow up questions someone will be in touch after we have processed the request.


A summary of this form, including the assigned project number will be emailed to you upon successful completion.


Project Approval Request Form

(Maximum characters: 50)
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(Maximum characters: 250)
You have February 13, 2015"250"> characters left.

External Collaborating Organizations:


Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Yes No
Yes No

Primary Contact:

First Name Last Name Email

Approved by: (Name of Departmental / Unit administrator or faculty member approving this project)

First Name Last Name Department

Send summary to:
(Please enter only the first part of your address)

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"The mission of the Office of Community Health and Service is to provide leadership and coordination in engaging our communities to improve health and well being through citizenship, service, education, research and advocacy."


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