Clinical Rotations & Preceptorships

First Name *

Last Name *

Professional Designation

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Requested *

Clinical rotation

Preceptorship

OtherOther

START DATE for consideration *

END DATE for consideration *

Preferred day(s) of the week *

Time requested *

Full day

Half day

Medical specialty or interest: (Eg. Palliative care)

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Grant Approved

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Intention of participation *

Academic

Clinical experience

Continuing education,

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Date requested for initial 15 minute interview *

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