Clinical Experience Request Form

This form is not applicable to nurse practitioner (NP) students. Contact NP Admissions if you are an NP student and have questions.

Contact Medical Education at mchsnwwisturot@mayo.edu or call 715-464-2224 with questions.

Personal Information

School Information

School name:

Address:

City:

State:

ZIP code:Use 5-digit ZIP code

Degree/certificate to be obtained:

Expected completion date:

Clinical Experience Information

Experience start date:

Experience end date:

Number of hours required:

Type of experience requested:

Rotator (experience is required for current degree/graduation)

Observer (experience is not required for current degree/graduation)

Pre-Approved Rotator (experience is required for current degree and has been approved by Mayo faculty)

Description of experience requested (include department):Maximum length of 1,500 characters.

If a Mayo Clinic preceptor has been contacted directly, enter the details of the conversations:Maximum length of 1,500 characters.

Preferred Mayo Clinic Health System location:

Why would you like to rotate in the requested location?Maximum length of 1,500 characters.

How will this add value to your career path and what do you hope to gain?Maximum length of 1,500 characters.

Program Information (non-Mayo Clinic employee)

Program director name:

Phone:

Program director email:

Emergency Contact Information

Emergency contact name:

Relationship:

Phone:

Alternative phone:

Comments, Questions or Concerns:Maximum length of 1,500 characters.