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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
Today's date:
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
Date of birth:
(Please use format mm/dd/yyyy)
Country of origin:
Country of citizenship:
Are you an officer or employee of a non-U.S. government-owned or controlled enterprise including public international organizations or a non-U.S. political party or party candidate?
Yes
No
Gender:
Male
Female
Other
Prefer not to disclose
Email:
Phone:
Format: xxx-xxx-xxxx
Alternative phone:
Format: xxx-xxx-xxxx
Are you a current or former employee/student of Mayo Clinic/Mayo Clinic Health System?
Yes
No
If yes, enter location and dates:
500 character limit
Have you ever been arrested or convicted of a felony?
Yes
No
If yes, provide date and details of the incident(s):
1,000 character limit
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:
Southeast Minnesota - Albert Lea
Southeast Minnesota - Austin
Southeast Minnesota - Owatonna
Southeast Minnesota - Red Wing
Southwest Minnesota - Fairmont
Southwest Minnesota - Mankato
Southwest Minnesota - New Prague
Southwest Minnesota - St. James
Southwest Minnesota - Waseca
Southwest Wisconsin - La Crosse
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