Clinical Experience Request Form

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):

If a Mayo Clinic preceptor has been contacted directly, enter the details of the conversations:

Preferred Mayo Clinic Health System location:Please see the Mayo Clinic Health System map.

Why would you like to rotate in the requested location?

How will this add value to your career path and what do you hope to gain?

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: