Clinical Experience Request Form

Personal Information

Form completed by:

Student

School Personnel

If school personnel, name and title:

First Name:

Last name:

Address:

City:

State:

ZIP code:Use 5-digit ZIP code

Email:

Phone:

Alternative phone:

Are you a current or former employee/student of Mayo Clinic/Mayo Clinic Health System?

Yes

If yes, enter location and dates:

Have you ever been arrested or convicted of a felony?

Yes

If yes, provide date and details of the incident(s):

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:

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 region:

Northwest Wisconsin (Barron, Bloomer, Chippewa Falls, Eau Claire, Menomonie, Osseo)

Southeast Minnesota (Albert Lea, Austin, Owatonna, Red Wing)

Southwest Minnesota (Fairmont, Mankato, New Prague, Springfield, St. James)

Southwest Wisconsin (La Crosse)

Please see the Mayo Clinic Health System map.

Why would you like to rotate in the requested region?

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

Instructor Information (non-Mayo Clinic employee)

Clinical instructor name:

Phone:

Instructor Email:

Emergency Contact Information

Emergency contact name:

Relationship:

Phone:

Alternative phone:

Comments, Questions or Concerns:

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