Externship Request Form
Questions marked with a
Student Last Name
Student First Name
Student Phone Number
-- Select --
Externship Site Approval Visit
to determine if your externship site is already approved.If it is not on the approved list, your request will be sent to Dr. Lane and will require extra time for processing. Is your externship site already on the approved list?
Requested Externship Practice/Organization
Requested Practice/Organization Street Address
City, State, & Zip Code of Externship
Externship Coordinator/Supervisor/Mentor FIRST & LAST Name
(person who will complete your grade form)
Mentor Phone Number
It is essential that your
e-mail is entered here, or
you might not get a grade for this rotation
. Our office sends an e-mail with instructions to the extern director the week prior to your externship.
Dates of Externship
(Any alteration in externship dates listed in the one45 schedule must first be approved using a PAPER copy of the
Schedule Change Form
1. Include a short paragraph (MAXIMUM length, 5,000 characters–about 700 words) describing why you want to do this particular externship. Explain how it will affect or impact your educational and/or immediate or long-term career goals.
: I want to observe a high volume spay-neuter shelter medicine practice that operates out of a no-kill shelter. My long-term goal is to seek specialty boards in shelter medicine and this shelter will give me the opportunity to work in a state-of-the-art facility and observe the role of a boarded specialist in the operations of the shelter, interface with the community and to assure my career aspirations are correctly aligned with the typical job.
2. Provide a minimum of 3 specific, action-oriented, measurable learning objectives you expect to achieve during this externship experience (what specific skills or knowledge do you hope to practice or gain?). You must give specific objective examples or your request will be returned.
1. I want to spay 30 normal female cats and 5 gravid cats.
2. I want to practice lameness exam skills.
3. I want to learn chemotherapy protocols used in private practice.
3. Provide a description of the practice/institution/facility/etc.
Include the following:
General focus (i.e. small animal practice, mixed animal practice, nutrition research, etc.)
Number of veterinarians/faculty/researchers/staff/etc.
Other pertinent information.
Often, a practice’s client information brochure will provide this information, or a specific information sheet describing the externship may be available
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