Clinical Experience Request Form

Personal Information
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School Information
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Student type:
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i.e., first semester
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Clinical Experience Information
Experience start date:
Experience end date:
Shift:




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Days of experience:




Check all that apply
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Type of experience:



Check all that apply
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Instructor Information
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Backup Contact Information

Backup contact information (preferably chair of the department) will be used only when the clinical instructor cannot be reached.

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Will an instructor be present with the student during the clinical experience?
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Is there a need for individual preceptors for each student?
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Interventions validated in skills lab
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Additional Experiences
Are additional experiences desired?
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Note: The following are available for alternative experiences: Intensive Care Unit (ICU), Medical Oncology/Radiation Oncology, Dialysis, Cardiac Rehabilitation, Operating Room, Endoscopy, Clinics, Hospice, Same Day Surgery/Post Anesthesia Care Unit, Diabetes Education, Wound Care, Joint Camp, Resource Team, Patient Admissions, Case Managers, Behavioral Health, Waseca, Springfield and St. James.
i.e., two 4-hour experiences per student or one 8-hour experience per student.