Clinical Experience Request Form

This form is not applicable to Nurse Practitioner (NP) Students, visit our NP page for information.

Note helpful hints on some fields. The form will not submit if hints are not followed.

Personal Information

School Information

School name:

Address:

City:

State:

ZIP code:Use 5-digit ZIP code

Degree/certificate to be obtained:512 character limit

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):1,000 character limit

If a Mayo Clinic preceptor has been contacted directly, enter the details of the conversations:1,000 character limit

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

Why would you like to rotate in the requested location?1,000 character limit

How will this add value to your career path and what do you hope to gain?1,000 character limit

Program Information (non-Mayo Clinic employee)

Program director name:

Phone:Format: xxx-xxx-xxxx

Program director email:

Emergency Contact Information

Emergency contact name:

Relationship:

Phone:Format: xxx-xxx-xxxx

Alternative phone:Format: xxx-xxx-xxxx

Comments, Questions or Concerns:1,000 character limit