Student Rotation Application 2.0

Student Rotation Application
Student Type (while on rotation):
Choose the student type you will be at the time of your rotation.
Previous Inspira Student Rotation
Do you still have your badge?
What is your badge number?
Have you used Epic within the last 12 months?
Students who have used Epic within the last 12 months are eligible to test out of training. Would you like to test out?
Is this an audition?
Rotation Location:
Choose a location to see available rotations in the next dropdown.
Specify Other:
Rotation Requested:
Specify Other:
Rotation Requested
Preceptor Name:
Preceptor Email:
example@example.com
1st Preferred Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
2nd Preferred Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Length of Rotation:
Please specify other length of rotation
Student Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address (medical school):
example@example.com
Last four digits of SSN:
Emergency Contact Information:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Medical School Name:
Have you ever failed a licensing exam such as COMLEX 1/USMLE Step 1?
COMLEX/USMLE Transcript Upload:

Board exam transcript(s) must be uploaded or this rotation request will be considered incomplete and will not be reviewed.
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Have you ever been placed on academic probation or had to repeat/remediate any courses during medical school?
If yes, please explain.
What specifically about our program aligns with your career goals?
Please provide 2–3 personal learning goals you hope to achieve during your rotation. You may include clinical skills, knowledge areas, or professional development goals.
Short Essay - 300 words or less. Please indicate your interest in completing an General Surgery rotation and why your chose Inspira.
Required Forms

Please review and acknowledge the Orientation paperwork and Dress Code Policy.
Student Paperwork

Please download, sign, and reupload when prompted below.
Please attach and complete all necessary documents below. These documents include:
- SIGNED Student Paperwork
- Professional Headshot (passport style)
- Immunization Records
- Current TB Test (within a year of rotation dates)
- Flu Shot
- Covid Vaccination Card (Unless documented on the immunization records)
- Covid Questionnaire
- Flu Questionnaire
Student Paperwork SIGNED

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Headshot

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Immunization Records

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Valid Flu Shot (September - June)

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Current TB Test

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Covid Vaccination Card

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Thank you for submitting and uploading all required documents for your upcoming student rotation. We will follow up via email with additional information once your application has been fully processed and completed.
Specify Other:
Should be Empty:

Student Rotation Application

Required Forms

Student Paperwork